A healthcare provider is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

Correct Answer: B

Rationale: The correct answer is B: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. It is important to assess a newborn's respiratory rate to ensure proper oxygenation. Option A (22/min) is too low, while options C (100/min) and D (110/min) are too high and could indicate respiratory distress or other issues that need immediate attention. Therefore, option B falls within the expected reference range and is the correct answer for a healthy newborn assessment.

Correct Answer: B

Rationale: The correct answer is B: Your son is displaying an adverse sibling response. This is the correct answer because the 4-year-old's regression in toilet training is likely a response to the recent birth of a new sibling. This behavior is common as the older child may feel jealous or neglected, leading to regression. Providing this statement will help the client understand the underlying cause of the behavior and address it appropriately. Incorrect choices: A: This choice suggests the child was not ready for toilet training, which is not the primary issue here. C: Counseling may be beneficial in some cases but is not the first-line intervention for this situation. D: Enrolling in preschool may not directly address the underlying cause of the behavior, which is related to the new sibling.

Correct Answer: B

Rationale: The correct answer is B: Suction the mouth with a bulb syringe. This is the priority action because secretions in the mouth can obstruct the airway and lead to respiratory distress. Suctioning the mouth first helps clear the airway effectively. Suctioning the nose with a bulb syringe (choice A) may not address the immediate risk of airway obstruction. Using a suction catheter with low negative pressure (choice C) can be too strong for a newborn. Turning the newborn on their side (choice D) may not effectively address the airway obstruction from secretions in the mouth.

Correct Answer: B

Rationale: The correct answer is B because it demonstrates the client's understanding that a second vaccination is needed, which is crucial for developing adequate immunity against varicella. This statement shows comprehension of the vaccination schedule and the importance of completing the series for full protection. Option A is incorrect as it suggests the need for a second vaccination but lacks conviction. Option C is incorrect because it only states the purpose of the vaccine without addressing the need for a second dose. Option D is incorrect as it mentions testing for immunity status, which is not typically necessary after receiving the varicella vaccine.

Correct Answer: C

Rationale: The correct answer is C: Sore nipple with cracks and fissures. This is indicative of possible breastfeeding issues like improper latch or infection, requiring prompt intervention to prevent complications. Scant, non-odorous white vaginal discharge (A) is normal postpartum lochia. Uterine cramping during breastfeeding (B) is common due to oxytocin release. Decreased response with sexual activity (D) is a common postpartum concern but not an urgent issue at 4 weeks. Addressing sore nipples promptly is crucial for successful breastfeeding and maternal well-being.

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation. Monitoring oxygen saturation is crucial in evaluating the newborn's respiratory status post-surfactant administration. It helps assess the effectiveness of surfactant therapy in improving oxygenation. Body temperature and serum bilirubin are not directly related to assessing respiratory distress syndrome. Heart rate may be affected by various factors and may not provide specific information on respiratory status.

Correct Answer: D

Rationale: The correct answer is D: Assist the client to the bathroom to void. A boggy and displaced fundus to the right in a postpartum client suggests a full bladder, which can displace the uterus. Voiding helps the uterus contract back to its normal position, reducing the risk of postpartum hemorrhage. Encouraging Kegel exercises (A) is not appropriate in this situation. Moving to the left lateral position (B) may provide temporary relief but does not address the underlying issue. Asking the client to rate her pain (C) is not relevant to the management of a displaced fundus.

Correct Answer: C

Rationale: The Apgar score assesses the newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 6 at 1 minute indicates moderate difficulty in transitioning to extrauterine life. For a score of 6, the baby may have a heart rate below 100 bpm, weak respiratory effort, some muscle tone, grimacing reflex irritability, and a body with bluish extremities but normal body color. Choice C aligns with these criteria. Choices A, B, and D do not meet the requirements for a score of 6 as they represent either too low or too high values in one or more criteria, resulting in a different Apgar score.

Correct Answer: D

Rationale: The correct answer is D because the Moro reflex is elicited by sudden head movement or loud noise, causing the infant to extend their arms, then bring them back in a hugging motion. By holding the newborn in a semi-sitting position and allowing their head and trunk to fall backward, the nurse can observe the Moro reflex. Choices A, B, and C do not correctly elicit the Moro reflex as they involve different stimuli or movements that do not trigger the characteristic response of arm extension followed by flexion.