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 C

Explanation

The correct answer is choice C, "Increased muscle weakness." The nurse should instruct the client to report increased muscle weakness, as this can indicate toxicity from magnesium sulfate. Increased fetal movement is not an indication of toxicity from magnesium sulfate. Increased respiratory rate is a common side effect of magnesium sulfate and does not require intervention unless it is significantly increased. Increased urinary output is a normal effect of magnesium sulfate and does not require intervention.

A. Rust-stained urine B. Transient circumoral cyanosis C. Single palmar creases D. Subconjunctival hemorrhage

Correct Answer is C

Explanation

A. Rust-stained urine: This is a common finding in newborns and is due to urate crystals in the urine. It is benign and typically resolves as the infant's kidney function matures.

B. Transient circumoral cyanosis: This is a common finding in newborns, particularly during crying or feeding, and it usually resolves on its own. It does not typically indicate a serious condition.

C. A single palmar crease (also known as a simian crease) can be a normal variant, but it is often associated with certain congenital anomalies or chromosomal disorders, such as Down syndrome. The nurse should report this finding to the provider for further evaluation and possible genetic testing.

D. Subconjunctival hemorrhage: This can occur during delivery due to the pressure of vaginal birth. It is harmless and usually resolves within a few weeks without treatment.

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

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