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A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?

A.

Blue coloring of the hands and feet in an 8-hour-old newborn.

B.

Small raised pearly spots on the newborn's nose.

C.

Apical heart rate of 140 bpm.

D.

Nasal flaring and grunting.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.

 

Choice B rationale

Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.

 

Choice C rationale

An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.

 

Choice D rationale

Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.

 


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View Related questions

Correct Answer is A

Explanation

Step 1 is: October 17 + 7 days = October 24.

Step 2 is: October 24 - 3 months = July 24.

Step 3 is: July 24 + 1 year = July 24. Answer: July 24 (0724)

Correct Answer is D

Explanation

Choice A rationale

Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.

Choice B rationale

Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.

Choice C rationale

Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.

Choice D rationale

A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .

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