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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Platelets 170,000/mm³ is a normal platelet count in pregnancy. The normal range for platelets in pregnancy is 150,000 to 450,000/mm³⁷⁸.
B. This HbA1c level indicates good control of blood glucose levels over the past 2-3 months. For a pregnant woman with type 1 diabetes, a target HbA1c of less than 6-7% is often recommended to reduce the risk of complications.
C. This blood urea nitrogen (BUN) level is elevated. Normal BUN levels typically range from 7 to 20 mg/dL. Elevated BUN may indicate renal impairment, which can be a concern for a pregnant woman with type 1 diabetes, as it could suggest developing diabetic nephropathy or other kidney-related issues.
D. Hct 34% is a normal hematocrit level in pregnancy. The normal range for hematocrit in pregnancy is 30% to 36%.
Correct Answer is B
Explanation
This is the action that the nurse should take after recognizing an early deceleration of the fetal heart rate tracing. Early decelerations are symmetrical decreases and return-to-normal linked to uterine contractions¹. The decrease in heart rate occurs gradually, and the nadir of the deceleration occurs at the same time as the peak of the uterine contraction³. Early decelerations are caused by compression of the fetus's head during a uterine contraction, which can stimulate the vagus nerve and cause a decrease in the fetal heart rate⁴. Early decelerations are nothing to be alarmed about¹. They are considered normal and benign, as they do not affect fetal oxygenation or well-being³. Therefore, the nurse should continue to monitor the client and the fetal heart rate tracing and document the findings.
The other options are not correct because they are not appropriate actions for early decelerations.
a) Assist the client to lay on her right side.
This is not an appropriate action for early decelerations, as they are not caused by maternal position or uteroplacental insufficiency. Changing the maternal position may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.
c) Discontinue the oxytocin.
This is not an appropriate action for early decelerations, as they are not caused by oxytocin administration or uterine hyperstimulation. Oxytocin is a hormone that stimulates uterine contractions and can be used to induce or augment labor. However, excessive or prolonged use of oxytocin can cause uterine fatigue and reduce its ability to contract after delivery, leading to uterine atony and postpartum hemorrhage². Oxytocin can also cause late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.
d) Administer oxygen at 8 L/min per mask.
This is not an appropriate action for early decelerations, as they are not caused by fetal hypoxia or acidosis. Oxygen administration may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.
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