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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 B

Explanation

Choice A rationale

Accidental lacerations are possible during a cesarean delivery, but they are typically managed quickly and are not the most critical issue immediately after birth.

Choice B rationale

Respiratory distress is the priority assessment for a newborn following a cesarean delivery because cesarean births can increase the risk of transient tachypnea or other respiratory complications due to the lack of labor-induced respiratory adaptation.

Choice C rationale

Hypothermia is a concern for all newborns, but respiratory distress takes precedence in the immediate post-delivery period, especially following cesarean delivery.

Choice D rationale

Acrocyanosis is a common and typically benign condition in newborns, not requiring immediate intervention compared to respiratory distress.

Correct Answer is B

Explanation

Choice A rationale

Open heart surgery is unrelated to the development of vaginal fistulas.

Choice B rationale

Tissue trauma from childbirth can cause vaginal fistulas, as prolonged labor or obstetric interventions can damage vaginal tissue and lead to fistula formation.

Choice C rationale

Diabetes mellitus does not directly cause vaginal fistulas, although it can affect overall tissue health and healing.

Choice D rationale

Preeclampsia, while a serious pregnancy complication, is not a direct cause of vaginal fistulas.

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