July 26 -NCLEX Daily Practice Questions

Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory distress should be evaluated promptly to determine necessary treatment (Option 1).

Jaundice, especially in the first 24 hours of life (pathologic): Yellowish hues may be initially noted on the face or eyes and progress to the trunk and extremities (Option 4).

Although newborn jaundice after 24 hours of life is usually physiologic and resolves spontaneously, it should still be reported and monitored closely to ensure resolution.

No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth. Not voiding on the first day of life or in the past 24 hours is concerning for a structural anomaly or dehydration (Option 5).

• (Option 2) Desquamation (peeling skin) is a normal finding in some newborns, especially those born at late- or post-term gestation. Moisturizers can be applied if desired, but desquamation resolves on its own over several days.
• (Option 3) Average newborn head circumference is approximately 13-14 in (33-35 cm). A smaller or larger head circumference may indicate an abnormal condition (eg, microcephaly, hydrocephalus).

Educational objective: When caring for newborns, the nurse should recognize abnormal findings (eg, jaundice, failure to void within 24 hours, signs of respiratory distress [eg, chest wall retractions]), and report them to the health care provider for further assessment.