A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?

Respiratory rate 55/min

Blood pressure 80/50 mm Hg

Temperature 36.5°C (97.7°F)

Heart rate 72/min

Answer and Explanation

The Correct Answer is D

Heart rate is one of the vital signs that reﬂects the health and well-being of a newborn. It is measured by counting the number of heart beats per minute, either by listening to the chest with a stethoscope or by feeling the pulse at the wrist, elbow, or groin. Heart rate can vary depending on the newborn's activity level, temperature, and emotional state¹.
The normal range for heart rate in full-term newborns is 120 to 160 beats per minute. The heart rate may be slightly higher or lower depending on the newborn's age, weight, and gestational age. For example, premature newborns may have a higher heart rate than term newborns, and heavier newborns may have a lower heart rate than lighter newborns¹².
A heart rate that is too high (tachycardia) or too low (bradycardia) can indicate a problem with the newborn's heart function, oxygenation, or circulation. Some of the possible causes of abnormal heart rate in newborns are:

-   Congenital heart defects: structural abnormalities of the heart that are present at birth and aﬀect the blood ﬂow through the heart and the body. They can cause cyanosis (bluish skin color), murmur (abnormal heart sound), poor feeding, or failure to thrive¹³.
-   Arrhythmias: irregular or abnormal heart rhythms that can aﬀect the electrical impulses that control the heartbeat. They can cause palpitations (feeling of skipped or extra beats), dizziness, fainting, or cardiac arrest¹³.
-   Hypoxia: lack of oxygen in the blood or tissues that can aﬀect the brain and other organs. It can be caused by respiratory distress, anemia, infection, or birth asphyxia. It can cause bradycardia, apnea (pauses in breathing), seizures, or coma¹⁴.
-   Hypothermia: low body temperature that can aﬀect the metabolism and organ function. It can be caused by exposure to cold environment, infection, or prematurity. It can cause bradycardia, lethargy, poor feeding, or hypoglycemia (low blood sugar)¹⁴.
-   Sepsis: severe infection that can aﬀect the whole body and cause inﬂammation and organ damage. It can be caused by bacteria, viruses, fungi, or parasites that enter the bloodstream from the mother, the umbilical cord, or the environment. It can cause tachycardia, fever, chills, poor feeding, or shock¹⁴.
Therefore, the nurse should report a heart rate of 72/min to the provider as an abnormal finding and monitor the newborn for any other signs of distress or illness. The provider may order further tests or treatments to determine the cause and severity of the low heart rate and prevent any complications.

The other findings are not findings that the nurse should report to the provider because they are within the
normal range for full-term newborns:
-   a) Respiratory rate 55/min is within the normal range for respiratory rate in full-term newborns. The normal range for respiratory rate in full-term newborns is 40 to 60 breaths per minute. The respiratory rate may vary depending on the newborn's activity level, temperature and emotional state¹².
-   b) Blood pressure 80/50 mm Hg is within the normal range for blood pressure in full-term newborns. The normal range for blood pressure in full-term newborns is 65 to 95 mm Hg for systolic pressure (the top number) and 30 to 60 mm Hg for diastolic pressure (the bottom number). The blood pressure may vary depending on the newborn's age, weight, and gestational age¹².
-   c) Temperature 36.5°C (97.7°F) is within the normal range for temperature in full-term newborns. The normal range for temperature in full-term newborns is 36.5°C to 37.5°C (97.7°F to 99.5°F). The temperature may vary depending on the newborn's activity level, clothing, and environment¹².

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Correct Answer is B

Explanation

Among the given options, the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L should be assessed first. Hyperemesis gravidarum is a condition characterized by severe and persistent vomiting during pregnancy, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L indicates hyponatremia, which is an abnormally low level of sodium in the blood.

Hyponatremia can lead to serious complications, including neurological symptoms such as confusion, seizures, and coma. Prompt assessment and intervention are necessary to correct the electrolyte imbalance and prevent further complications.

Option a) A client with preeclampsia and a creatinine level of 1.1 mg/dL should be monitored closely, as elevated creatinine levels can indicate impaired kidney function. However, in this scenario, the client with hyperemesis gravidarum and severe hyponatremia requires more immediate attention due to the potential for neurological complications.

Option c) A client with diabetes mellitus and an HbA1C of 5.8% may require further management and monitoring, but it does not present an immediate risk or urgency compared to the client with hyperemesis gravidarum and severe hyponatremia.

Option d) A client with placenta previa and a hematocrit of 35% may need close monitoring for potential bleeding, but it does not pose an immediate threat compared to the client with hyperemesis gravidarum and severe hyponatremia.

Therefore, the nurse should assess the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L as the first priority due to the risk of complications associated with severe hyponatremia.

A. Give the newborn a warm bath. B. Reposition the newborn. C. Obtain an oxygen saturation level. D. Apply a cap to the newborn's head.

Correct Answer is D

Explanation

A newborn who is 1 hour old and has a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.1°C (97°F) has normal vital signs for their age¹². However, the newborn is at risk of losing heat and developing hypothermia, which can cause serious complications such as hypoglycemia, metabolic acidosis, and respiratory distress³. Therefore, the nurse should take measures to prevent heat loss and maintain a neutral thermal environment for the newborn³⁴.
One of the eﬀective ways to prevent heat loss in newborns is to apply a cap to their head. The head has a large surface area relative to the body mass and can account for up to 50% of heat loss in newborns³⁴. A cap can reduce heat loss through radiation, convection, and evaporation from the scalp³⁴. The cap should be dry, clean, and snug-fitting, and should not cover the eyes or ears of the newborn³⁴.

a) Giving the newborn a warm bath is not an appropriate action for the nurse to take. Bathing can increase heat loss through evaporation and conduction, especially if the water temperature is not optimal or the room temperature is too low³⁴. Bathing should be delayed until the newborn's temperature is stable and preferably after the first breastfeeding session³⁴.
b) Repositioning the newborn is not a sufficient action for the nurse to take. Repositioning may help reduce heat loss through conduction if the newborn is placed away from cold surfaces or objects, but it does not address heat loss through other mechanisms³⁴. Repositioning should be combined with other interventions, such as skin-to-skin contact, swaddling, or radiant warmers³⁴.
c) Obtaining an oxygen saturation level is not a relevant action for the nurse to take. Oxygen saturation is a measure of how much oxygen is carried by the hemoglobin in the blood. It is not directly related to temperature regulation or heat loss in newborns³⁴. Oxygen saturation should be monitored routinely in all newborns before discharge as part of screening for congenital heart disease, but it does not address the risk of hypothermia⁵.

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A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?

Correct Answer is B

Explanation

A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.1°C (97°F). Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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