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).
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Listeriosis is a foodborne illness that can have severe consequences during pregnancy. To minimize the risk of listeriosis, a pregnant client should avoid certain foods that are more likely to be contaminated with the bacteria Listeria. The correct statement that indicates an understanding of the teaching is:
C) "I can eat grilled chicken on a bun at lunchtime."
Grilled chicken is a safe option, and as long as it's properly cooked, it's a suitable choice during pregnancy. The other options are not recommended during pregnancy:
A) Soft cheeses, like Brie or feta, can carry a risk of Listeria contamination, so they should be avoided.
B) Seafood salad from the grocery store may not be safe as it could contain seafood that's been sitting at improper temperatures, which can increase the risk of foodborne illness.
D) Hot dogs can also be a risk as they are often not served steaming hot, which is necessary to kill any potential Listeria contamination.
Correct Answer is B
Explanation
Choice A rationale:
A postpartum temperature of 37.4°C (99.3°F) is within the normal range. Mild temperature elevations can be expected in the immediate postpartum period without indicating infection.
Choice B rationale:
Uterine tenderness is a common finding in endometritis, which is an inflammation or infection of the inner lining of the uterus. The condition can cause pelvic pain and uterine tenderness.
Choice C rationale:
A white blood cell (WBC) count of 9,000/mm³ falls within the normal range for a postpartum client. In endometritis, an elevated WBC count would be expected due to the infection.
Choice D rationale:
Scant lochia (minimal vaginal discharge after childbirth) is a normal finding in the postpartum period and is not associated with endometritis. In endometritis, the lochia may be increased and foul-smelling.
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