What does the nursing process describe?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: B

Rationale: The correct answer is B: Heart rate of 145 beats per minute. This is expected in a newborn as their heart rate can range from 120-160 bpm. This indicates normal cardiac function. Choices A, C, and D are incorrect. A newborn's blood pressure is usually lower than 120/80. The normal temperature for a newborn is around 98.6-99.5°F. A respiratory rate of 62 breaths per minute is higher than normal for a newborn.

Correct Answer: C

Rationale: The Dubowitz/Ballard assessment tool is used to determine the neuromuscular and physical maturity of the newborn. This tool assesses various physical and neuromuscular characteristics to estimate the gestational age of the infant accurately. By evaluating factors such as skin texture, lanugo, ear formation, and posture, healthcare providers can assess the infant's developmental stage. This assessment helps in determining if the infant is born prematurely or post-term, guiding appropriate care and interventions. The other choices are incorrect because the tool is not primarily used for those purposes.

Correct Answer: B

Rationale: The correct answer is B: Suction the nose and then the mouth of the newborn to prevent aspiration. This is the most accurate statement because suctioning the nose first prevents any mucus or secretions from being pushed into the mouth during suctioning. Aspiration can occur if the baby inhales any secretions. Suctioning the mouth after the nose ensures that any remaining secretions are cleared. Choice A is incorrect because compressing the bulb syringe after insertion can cause trauma to the delicate nasal passages. Choice C is incorrect as using saline before suctioning is not necessary and may increase the risk of aspiration. Choice D is incorrect as placing the bulb syringe on the side of the infant's cheek is not an effective method for suctioning the mouth or nose.

Correct Answer: A

Rationale: The correct answer is A because larger labia minora relative to labia majora is a characteristic of preterm babies due to incomplete development. Labia minora being larger is a sign of immaturity in female infants. Choices B, C, and D are incorrect because plantar creases covering two-thirds of the foot, mostly absent lanugo, and ears with instant recoil are normal characteristics seen in full-term newborns. These features are signs of maturity and development, not indicators of prematurity.