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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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Correct Answer is D

Explanation

Choice A rationale

An apical pulse rate of 124 bpm is within the normal range for a neonate (110-160 bpm). There is no need to ask another nurse to verify the heart rate as it is not an abnormal finding.

Choice B rationale

Calling the provider for an apical pulse rate of 124 bpm is unnecessary as it is within the normal range for a neonate. This action would be appropriate if the heart rate were significantly outside the normal range.

Choice C rationale

Preparing the newborn for transport to the NICU for an apical pulse rate of 124 bpm is not warranted. The heart rate is within the normal range, and there is no indication for further cardiac observation.

Choice D rationale

Documenting the expected finding is the appropriate action. An apical pulse rate of 124 bpm is within the normal range for a neonate, and no further action is needed.

Correct Answer is D

Explanation

Choice A rationale

Stretching arms out and then back in is a common reflex in newborns known as the Moro reflex. It is not a sign of feeding readiness but rather a response to a sudden loss of support or a loud noise.

Choice B rationale

Turning the head toward a parent’s voice is a sign of auditory recognition and bonding, not necessarily feeding readiness. It indicates the infant’s ability to recognize familiar sounds.

Choice C rationale

Grasping a parent’s finger when placed in the infant’s palm is a primitive reflex known as the palmar grasp reflex. It is not related to feeding readiness but is a normal reflexive action in newborns.

Choice D rationale

Bringing their hand to their mouth is a sign of feeding readiness. This action indicates that the infant is hungry and ready to feed. It is an early cue that the baby is ready to eat.

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