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
A. Monitor the rectal temperature every 4 hr: Rectal temperature measurement is contraindicated in this newborn due to the risk of trauma to the spinal cord or irritation of the leaking sac. Axillary temperature monitoring is a safer alternative.
B. Administer broad-spectrum antibiotics: Broad-spectrum antibiotics help prevent infection from organisms entering through the exposed or leaking sac. This is a priority intervention to ensure the safety of the newborn.
C. Cleanse the site with povidone-iodine: Povidone-iodine is not recommended for cleansing the sac, as it can cause irritation or toxicity. Instead, the sac should be kept clean and moist with a sterile, saline-soaked dressing.
D. Prepare for surgical closure after 72 hr: Surgical closure of the defect is typically performed within 24 to 48 hours after birth to minimize infection risk and prevent further damage to neural tissue. Waiting beyond this window is not standard practice for a leaking myelomeningocele.
Correct Answer is C
Explanation
The nurse should report a respiratory rate of 10/min to the provider following the administration of butorphanol IV bolus. Butorphanol is an opioid agonist-antagonist analgesic that can cause respiratory depression as a side effect. Therefore, it is important to monitor the client's respiratory rate and depth closely after administration of the medication. A respiratory rate of 10/min is significantly lower than the normal range of 1220/min, and may indicate respiratory depression. The nurse should also monitor the client's blood pressure, urinary output, and fetal heart rate for any changes, but these findings are not necessarily indicative of a complication following the administration of butorphanol.
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