Practice Question
A nurse is caring for a newborn.
Answer Choices:
Rationale:
Irritability (Neurologic finding)
💎Newborn irritability, when accompanied by abnormal vitals or other concerning signs, is a potential indicator of central nervous system involvement or neonatal infection.
💎Given the prolonged rupture of membranes (PROM), the newborn is at increased risk for neonatal sepsis caused by ascending bacterial infection.
💎Elevated C-reactive protein (2.5 mg/dL) and WBC (40,000/mm³) confirm an inflammatory response consistent with infection.
💎Early irritability often precedes lethargy or poor feeding, which can rapidly progress if untreated. The nurse should report this promptly for further evaluation and blood cultures.
Axillary temperature 36.2°C (97.2°F)
💎This temperature indicates hypothermia (normal range: 36.5–37.5°C), which is abnormal for a full-term infant.
💎Hypothermia in newborns can result from sepsis, poor thermoregulation, or environmental exposure.
💎It can cause hypoglycemia and respiratory distress as the infant expends excess energy to maintain warmth.
💎The nurse should initiate warming measures (radiant warmer, skin-to-skin) and notify the provider, as hypothermia may mask infection or metabolic dysfunction.
Respiratory rate 80/min
💎The normal newborn respiratory rate is 30–60/min. A rate of 80/min indicates tachypnea, a hallmark of respiratory distress.
💎The combination of tachypnea and grunting suggests alveolar collapse, fluid retention, or sepsis-related respiratory compromise.
💎This finding warrants immediate provider notification for oxygen saturation assessment and possible supplemental oxygen or antibiotic therapy.
💎The newborn’s expiratory grunting further indicates attempted airway stabilization due to poor gas exchange.
Abdomen hard and distended (Gastrointestinal finding)
💎A firm, distended abdomen in a neonate indicates abdominal pathology such as necrotizing enterocolitis (NEC), meconium ileus, or sepsis-related ileus.
💎This is not normal for a newborn, especially with dark, tarry stool and infection signs.
💎Abdominal distention can result in impaired diaphragmatic movement, worsening respiratory distress.
💎The nurse must report this finding immediately, withhold oral feedings, and prepare for radiographic evaluation and potential decompression if ordered.
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This question is from RN Maternal Newborn 2023 OCT 28 which contains 66 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 1