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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Administering oxygen is unnecessary for early decelerations because they are not caused by fetal hypoxia or distress.
B.Discontinuing oxytocin is indicated for late decelerations or signs of fetal distress, not early decelerations.
C.Positioning the client on her side may help with certain decelerations, but it is not required for early decelerations caused by head compression, which is expected in active labor.
D.Early decelerations in the fetal heart rate are typically benign and often associated with fetal head compression during contractions. These decelerations usually mirror the contraction pattern and do not indicate fetal distress. Therefore, continuing to monitor the client is the appropriate action, as early decelerations are a normal finding during active labor.
Correct Answer is C
Explanation
The correct answer is choice C, "Maintain scheduled mealtimes for yourself." The nurse should instruct the postpartum client with type 1 diabetes mellitus and who is breastfeeding her newborn to maintain scheduled mealtimes for herself to ensure stable blood glucose levels. The client should also monitor her blood glucose levels more frequently, aiming to maintain a level between 60 to 99 mg/dL before meals and less than 120 mg/dL one hour after meals. Breastfeeding can cause hypoglycemia, so the client should have a source of glucose nearby while nursing. The client should consume a balanced diet, including fruits, vegetables, whole grains, lean proteins, and low-fat dairy, and aim to consume at least 175 g of carbohydrates per day.
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