A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?
Respiratory rate 55/min
Heart rate 72/min
Temperature 36.5° C (97.7° F)
Blood pressure 80/50 mm Hg
The Correct Answer is B
A. A respiratory rate of 55 breaths per minute is within the normal range for a full-term newborn, which is generally between 30 and 60 breaths per minute.
B. A heart rate of 72 beats per minute is significantly lower than the normal range for a newborn. Normal heart rates for newborns typically range from 120 to 160 beats per minute. A heart rate this low could indicate bradycardia, which requires immediate assessment and intervention.
C. A temperature 36.5° C (97.7° F) is slightly below the normal range for newborns, which is typically between 36.6°C to 37.2°C (97.9°F to 99.0°F). However, it may not be immediately concerning unless it is part of a pattern or accompanied by other symptoms.
D. A blood pressure reading of 80/50 mm Hg is within the expected range for a full-term newborn, where typical values are approximately 60-80 mm Hg for systolic and 40-50 mm Hg for diastolic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Newborns born to mothers with gestational diabetes mellitus are at risk for hypoglycemia, which is a condition characterized by low blood sugar levels. Jitteriness is a common sign of hypoglycemia in newborns. Other signs of hypoglycemia include poor feeding, lethargy, seizures, and apnea.
Choice A, petechiae, refers to small, pinpoint, red or purple spots on the skin caused by bleeding under the skin. It is not a common manifestation of hypoglycemia. Choice C, increased muscle tone, is not a common manifestation of hypoglycemia and may indicate other conditions such as cerebral palsy. Choice D, abdominal distention, may indicate other conditions such as intestinal obstruction or infection, but is not a common manifestation of hypoglycemia.
Correct Answer is D
Explanation
The correct answer is choice D. Urine output of 20 mL/hr is a manifestation of an adverse reaction to magnesium sulfate. Magnesium sulfate is a medication used to treat preeclampsia, a potentially life-threatening condition that can occur during pregnancy. Adverse reactions to magnesium sulfate include hypotension, respiratory depression, and decreased urine output. The nurse should monitor the client's vital signs and urine output closely while the client is receiving magnesium sulfate. Normal urine output in a healthy individual should be between 0.5-1.5 mL/kg/hour, and patients should generally be urinating at least every 6 hours.
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