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)
Flexion of arms.
Caput succedaneum.
Heart rate 158 bpm.
Respiratory rate 66/min.
Acrocyanosis.
Subcostal retractions.
Nasal flaring.
Grunting.
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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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. .