The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation
While taking vital signs and changing the newborn's diaper, the nurse observes the newborn's color is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and heart rate is regular and rapid. The nurse should recognize these behaviors as manifestations of:
a. stress.
b. subtle seizures.
c. preterm behavior.
d. onset of respiratory distress.
ANS: A
Color pink but slightly mottled, arms and legs limp and extended, hiccups, respiratory pauses and gasping, and an irregular, rapid heart rate are signs of stress or fatigue in a newborn. Neonatal seizures usually have some type of repetitive movement from twitching to rhythmic jerking movements. The behavior of a preterm newborn may be inactive and listless. Respiratory distress is exhibited by retractions and nasal flaring.
You might also like to view...
A pregnant client is in the clinic for a routine monthly check and asks the nurse whether there is a blood test that can be drawn to check for genital warts. The best response by the nurse is:
1. "Yes, I will ask the doctor to draw the blood." 2. "No, but we can culture your vagina." 3. "There are several types of laboratory tests, but you need to speak to the physician." 4. "Genital warts are detected by inspection or by culturing the cervix for HPV."
The client with a normal pregnancy had an emergency cesarean birth under general anesthesia 2 hours ago. The client now has a respiratory rate of 30, pale blue nail beds, a pulse rate of 110, and a temperature of 102
6°F, and is complaining of chest pain. The nurse understands that the client most likely is experiencing which of the following? 1. Pulmonary embolus 2. Pneumococcal pneumonia 3. Pneumonitis 4. Gastroesophageal reflux disease
The nurse tells a joke to a 12-year-old to distract him from a painful procedure. What pain management technique is the nurse using?
A) Relaxation B) Distraction C) Imagery D) Thought stopping
Which reflex indicates an abnormality in the motor control pathways from the cerebral cortex?
a. Babinski reflex b. Biceps reflex c. Brachioradialis reflex d. Knee jerk reflex