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

Answer and Explanation

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.

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Correct Answer is D

Explanation

The nurse should explain to the client that amniocentesis is a diagnostic test that is performed between 15 and 20 weeks of gestation to determine if the fetus has genetic or congenital disorders. While the procedure can also determine the sex of the fetus, this is not typically the primary reason for the test. The nurse should clarify any misconceptions the client has about the procedure and provide education on its purpose, risks, and benefits. The nurse should also assess the client's understanding of the information provided and address any questions or concerns the client may have.

A. Give the newborn 1 oz of glucose water every 4 hr. B. Apply a thin layer of lotion to the newborn's skin every 8 hr. C. Ensure the newborn's eyes are closed beneath the shield. D. Dress the newborn in a thin layer of clothing during therapy.

Correct Answer is C

Explanation

The correct answer is choice C, Ensure the newborn's eyes are closed beneath the shield. Phototherapy is a treatment used to reduce high bilirubin levels in newborns. It involves exposing the newborn's skin to special lights, which helps to break down the excess bilirubin in the blood. It is important to ensure that the newborn's eyes are closed beneath the shield to prevent damage to the eyes from the bright lights. Giving the newborn 1 oz of glucose water every 4 hr, applying lotion to the newborn's skin every 8 hr, and dressing the newborn in a thin layer of clothing during therapy are not indicated interventions during phototherapy.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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