Practice Question
A nurse is caring for a newborn Immediately following birth.
Answer Choices:
Rationale:
🟥 Muscle tone: Flaccid → Sign of potential worsening condition
🟥 Flaccid tone is abnormal in a newborn and indicates hypotonia, which may suggest neurological depression, sepsis, or hypoxic-ischemic encephalopathy (HIE).
🟥 Given the risk of neonatal sepsis from maternal GBS, even with prophylaxis, this finding is concerning and requires immediate investigation (e.g., CBC, blood cultures).
🟥 Flaccid tone is often an early clinical indicator of worsening systemic infection or central nervous system dysfunction.
🟩 Respiratory effort: Good cry → Sign of potential improvement
🟩 A strong cry is a reassuring sign of adequate respiratory effort and suggests the newborn is effectively oxygenating and ventilating.
🟩 It indicates that the central nervous system is responsive and that the baby is not in significant distress.
🟩 This reflects normal Apgar respiratory scoring (2 points) and signals the absence of respiratory depression or severe infection.
🟩 Reflex irritability: Cry → Sign of potential improvement
🟩 Crying in response to stimulation demonstrates normal reflex irritability, suggesting intact neurologic function.
🟩 This is a positive sign of CNS activity and responsiveness, which supports that the baby is neurologically intact at that time.
🟩 It’s especially important in assessing neurologic deterioration in potentially septic neonates, where decreased reflexes could mean worsening status.
🟦 Color: Consistent with genetic background → Unrelated to diagnosis
🟦 Normal skin color for a newborn that matches the infant's ethnic or genetic background is expected and not diagnostic of infection or improvement.
🟦 While pallor or cyanosis would be signs of hypoxia or poor perfusion, this finding is neutral and not linked directly to GBS sepsis or recovery.
🟩 Heart rate: 140/min → Sign of potential improvement
🟩 A heart rate of 110–160 bpm is normal for newborns and reflects adequate perfusion and cardiac function.
🟩 In the context of potential sepsis, tachycardia (>160) or bradycardia (<100) would raise concern. A HR of 140 suggests stable cardiovascular status.
🟩 This is a positive sign, indicating the absence of shock or cardiovascular decompensation.
🟥 Axillary temperature: 36.3°C (97.4°F) → Sign of potential worsening condition
🟥 Neonatal sepsis may present with temperature instability, including hypothermia, which is a red flag.
🟥 A normal axillary temp ranges from 36.5°C–37.5°C (97.7–99.5°F). A temp of 36.3°C is below normal and must be closely monitored or treated as early hypothermia.
🟥 In a newborn at risk for GBS-related infection, this low temperature may signal impaired thermoregulation secondary to infection or metabolic dysfunction.
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This question is from RN Maternal Newborn 2023 which contains 62 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: General Exams
- Domain: 🤱🏼Maternity & Newborn Care
- Answer Choices: 0