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

Blood pressure 80/50 mm Hg.

Respiratory rate 55/min.

Heart rate 72/min.

Temperature 36.5°C (97.7°F).

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Heart rate 72/min.

Choice A rationale:

A blood pressure of 80/50 mm Hg is within the normal range for a full-term newborn.

Choice B rationale:

A respiratory rate of 55/min is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute.

Choice C rationale:

A heart rate of 72/min is significantly lower than the normal range for a newborn, which is typically between 120 to 160 beats per minute. This bradycardia should be reported to the provider as it may indicate an underlying issue.

Choice D rationale:

A temperature of 36.5°C (97.7°F) is within the normal range for a newborn, which is generally between 36.5°C to 37.5°C (97.7°F to 99.5°F).

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Correct Answer is C

Explanation

The correct answer is choice c. One acceleration of the FHR within a 20-min period.

Here's the rationale for each choice:

Choice A: Rationale: A non-stress test (NST) is supposed to assess fetal well-being by looking for accelerations in the fetal heart rate (FHR) in response to fetal movement. An FHR that peaks 20 beats above the baseline is a desirable finding in an NST, indicating good fetal reactivity.

Choice B: Rationale: While not typical during a standard NST, three uterine contractions within a 20-minute period might not necessarily require immediate intervention. However, the nurse should document it and notify the healthcare provider for further assessment, especially if the contractions are causing discomfort or if there are other concerning signs.

Choice C: Rationale: A single acceleration of the FHR within a 20-minute NST is considered non-reactive and may indicate fetal compromise. This finding requires further investigation by the healthcare provider, potentially including additional monitoring or interventions.

Choice D: Rationale: Uterine contractions lasting 20 to 30 seconds each are not a typical finding during an NST, but they may not necessarily be a cause for immediate concern unless they are causing the client pain or are accompanied by other concerning signs. The nurse should document the contractions and notify the healthcare provider.

A. "The nurse should determine the Apgar score at 2 and 7 minutes after birth.”. B. "The nurse should identify that the newborn is in severe distress with an Apgar score of 8.”. C. "The nurse should wait for the first Apgar score before initiating resuscitation efforts.”. D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score.".

Correct Answer is D

Explanation

The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”

Choice A rationale:

The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.

Choice B rationale:

An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.

Choice C rationale:

Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.

Choice D rationale:

Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.

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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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