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A nurse is assessing a newborn who is 12 hr old: True/ False Which of the following manifestations requires intervention by the nurse?

a) Acrocyanosis of the extremities
b) Murmur at the left sternal border
c) Substernal chest retractions while sleeping
d) Positive Babinski reflex

User Hamiltonia
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1 Answer

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Final answer:

The nurse should intervene for substernal chest retractions while the newborn is sleeping, as this could indicate respiratory distress. Acrocyanosis is typically not concerning, a murmur may need additional evaluation, and a positive Babinski reflex is normal.

Step-by-step explanation:

The question is assessing the understanding of newborn physical examination and the Apgar score, which is a quick test performed on a baby at 1 and 5 minutes after birth. The Apgar score is a comprehensive test that assesses a baby's heart rate, respiration, muscle tone, reflex response, and skin color. Each of these areas is given a score of 0, 1, or 2, which are then summed to produce the overall Apgar score.

In the context of the student's question:

  • (a) Acrocyanosis of the extremities is common in newborns and usually resolves within the first 24 hours after birth; it does not typically require intervention.
  • (b) A murmur at the left sternal border could be a benign finding or an indication of a congenital heart defect; additional evaluation is warranted.
  • (c) Substernal chest retractions while sleeping can be a sign of respiratory distress and need immediate intervention.
  • (d) A positive Babinski reflex is normal in newborns and not a cause for concern.

The manifestation that requires intervention by the nurse is the substernal chest retractions while the newborn is sleeping, as this may indicate respiratory distress.

User Chrischu
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