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The nurse is caring for a newborn one hour after delivery. Which of the following assessment findings does the nurse identify as signs of respiratory distress? (Select all that apply)

A.

Flexion of arms.

B.

Caput succedaneum.

C.

Heart rate 158 bpm.

D.

Respiratory rate 66/min.

E.

Acrocyanosis.

F.

Subcostal retractions.

G.

Nasal flaring.

H.

Grunting.

Question Solution

Correct Answer : D,F,G,H

Choice A rationale

 

Flexion of arms is a normal finding in newborns and does not indicate respiratory distress.

 

Choice B rationale

 

Caput succedaneum is a common condition where the scalp swells due to pressure during delivery. It does not indicate respiratory distress.

 

Choice C rationale

 

A heart rate of 158 bpm is within the normal range for newborns and does not indicate respiratory distress.

 

Choice D rationale

 

A respiratory rate of 66/min is above the normal range (30-60 breaths per minute) and indicates respiratory distress.

 

Choice E rationale

 

Acrocyanosis is common in newborns and does not indicate respiratory distress.

 

Choice F rationale

 

Subcostal retractions indicate increased work of breathing and are a sign of respiratory distress.

 

Choice G rationale

 

Nasal flaring is a sign of respiratory distress as it indicates increased effort to breathe.

 

Choice H rationale

 

Grunting is a sign of respiratory distress as it indicates difficulty in maintaining lung expansion.

 


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View Related questions

Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale

Sucking on their fingers is an early hunger cue in infants. It indicates that the baby is ready to feed.

Choice B rationale

Smacking their lips is another early hunger cue. It shows that the baby is thinking about feeding.

Choice C rationale

Extending their tongue is also an early hunger cue. It indicates that the baby is ready to latch onto the breast or bottle.

Choice D rationale

Crying is a late hunger cue. It is better to feed the baby before they start crying to make feeding easier.

Choice E rationale

Rooting is an early hunger cue. It involves the baby turning their head towards the breast or bottle, indicating they are ready to feed. .

Correct Answer is B

Explanation

Choice A rationale

Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.

Choice B rationale

A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.

Choice C rationale

Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.

Choice D rationale

A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .

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