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 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.

A. Labor induction with oxytocin B. History of human papillomavirus C. Vacuum-assisted delivery D. Newborn weight 2.948 kg (6 Ib 8 oz)

Correct Answer is ["A","C"]

Explanation

A. Labor induction with oxytocin: The use of oxytocin for labor induction can increase the risk of postpartum hemorrhage due to uterine atony, where the uterus fails to contract effectively after delivery.

B. History of human papillomavirus: A history of human papillomavirus does not directly increase the risk of postpartum hemorrhage.

C. Vacuum-assisted delivery: Instrumental deliveries, such as those using a vacuum, are associated with an increased risk of trauma to the birth canal, which can contribute to postpartum hemorrhage.

D. Newborn weight 2.948 kg (6 lb 8 oz): A newborn weight of 2.948 kg is within the normal range and does not by itself increase the risk of postpartum hemorrhage. Larger babies (macrosomia) are more commonly associated with an increased risk.

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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

A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication.

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings places the client at risk for postpartum hemorrhage? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

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