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
This is because urine protein of 3+ is a sign of preeclampsia, which is a complication of pregnancy that involves high blood pressure and damage to the kidneys or other organs¹². Preeclampsia can cause serious problems for both the mother and the baby, such as fetal growth restriction, placental abruption, preterm birth, eclampsia, and HELLP syndrome¹². The nurse should report this finding to the provider and monitor the client's blood pressure, reflexes, and fetal well-being. The client may need medication to lower blood pressure and prevent seizures, such as magnesium sulfate or antihypertensives¹².
The other options are not correct because:
a) Deep tendon reflexes of 2+ are normal and do not indicate preeclampsia. Deep tendon reflexes are graded from 0 to 4+, with 2+ being the average response⁶. Increased reflexes (3+ or 4+) may suggest hyperreflexia, which can be a sign of preeclampsia or magnesium toxicity¹⁶.
b) Blood glucose of 110 mg/dL is normal and does not indicate preeclampsia. Blood glucose is the amount of sugar in the blood, and it can vary depending on the time of day, diet, and activity level. The normal range for blood glucose is 70 to 130 mg/dL before meals and less than 180 mg/dL after meals⁷. High blood glucose (hyperglycemia) can be a sign of gestational diabetes, which is a type of diabetes that develops during pregnancy⁷.
d) Hemoglobin of 13 g/dL is normal and does not indicate preeclampsia. Hemoglobin is the protein in red blood cells that carries oxygen throughout the body. The normal range for hemoglobin is 12 to 16 g/dL for women and 14 to 18 g/dL for men⁷. Low hemoglobin (anemia) can be a sign of iron deficiency, bleeding, or infection⁷.
Correct Answer is A
Explanation
Urination is an important indicator of a newborn's hydration and kidney function. A newborn should urinate at least six times a day, or once every four hours, by the fifth day of life. The urine should be clear or pale yellow and have no strong odor or blood. A newborn who urinates less than six times a day may be dehydrated, have a urinary tract infection, or have a kidney problem .
Therefore, the nurse should instruct the client to monitor her baby's urination and notify the pediatrician if he urinates less than six times a day. The nurse should also teach the client how to prevent dehydration in her baby, such as:
- Feeding the baby frequently, either breast milk or formula, according to his hunger cues and weight gain
- Offering the baby extra fluids in hot weather or when he is sick
- Avoiding giving the baby water, juice, or cow's milk before six months of age
- Checking the baby's diapers for wetness and changing them promptly
- Checking the baby's mouth for dryness and his fontanelle for sunkenness
The other statements are not correct and should not be made by the nurse:
- b) "Swaddle your baby tightly with his legs extended before laying him down to sleep." This is not correct because swaddling a baby too tightly or with his legs extended can cause problems, such as overheating, hip dysplasia, or restricted breathing. The nurse should teach the client how to swaddle her baby safely and comfortably, such as:
- Using a thin blanket that is breathable and does not cover the baby's head or face
- Wrapping the blanket snugly around the baby's chest and arms, but leaving some room for his hips and legs to move freely
- Placing the baby on his back to sleep on a firm and flat surface with no pillows, blankets, or toys
- Stopping swaddling when the baby shows signs of rolling over or breaking free from the blanket
c) "Place triple antibiotic ointment on your baby's umbilical cord twice per day." This is not correct because placing ointment on the umbilical cord can delay its healing and increase the risk of infection. The nurse should teach the client how to care for her baby's umbilical cord until it falls off naturally, usually within one to two weeks after birth, such as:
- Keeping the cord clean and dry by using a cotton swab dipped in water or alcohol to gently wipe around it
- Folding the diaper below the cord to prevent irritation or wetness
- Dressing the baby in loose-fitting clothes that allow air circulation around the cord
- Avoiding bathing the baby in a tub until the cord falls off and heals
- Watching for any signs of infection, such as redness, swelling, pus, foul odor, or bleeding
d) "Retract the foreskin to clean your baby's penis during each bath." This is not correct because retracting the foreskin of a newborn can cause pain, injury, or infection. The foreskin of a newborn is usually attached to the head of the penis (glans) and does not need to be retracted for cleaning. The nurse should teach the client how to clean her baby's penis during each bath, such as:
- Using warm water and mild soap to gently wash the outside of the penis
- Rinsing well and patting dry with a soft towel
- Leaving the foreskin alone and never forcing it back
- Changing diapers frequently and keeping them clean and dry
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