A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
110/min
48/min
22/min
100/min
The Correct Answer is B
a. 110/min - This respiratory rate is higher than the expected reference range for a newborn. Newborns typically have respiratory rates between 30 to 60 breaths per minute.
b. 48/min - This respiratory rate falls within the expected reference range for a newborn, which is typically between 30 to 60 breaths per minute.
c. 22/min - This respiratory rate is lower than the expected reference range for a newborn. Newborns typically have respiratory rates between 30 to 60 breaths per minute.
d. 100/min - While this respiratory rate is within the expected range, it's at the upper end of the range for a newborn. Typically, newborns have respiratory rates between 30 to 60 breaths per minute, so a rate of 100/min may be considered slightly elevated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pain following a cesarean birth is important to address, but it may not indicate an urgent need for assessment compared to other potential complications.
B. A client with preeclampsia requires close monitoring of blood pressure to prevent
complications such as eclampsia, which can lead to seizures and other serious consequences. An elevated blood pressure reading warrants immediate attention.
C. A client scheduled for discharge following a laparoscopic tubal ligation is stable and can likely wait for assessment until after higher-priority clients have been seen.
D. While it's important to monitor for bleeding after a vaginal birth, the absence of bleeding reported by a client 24 hours postpartum may not indicate an immediate need for assessment compared to the potential urgency of managing preeclampsia.
Correct Answer is A
Explanation
A. The nurse's response to have the mother call ensures proper protocol is followed for infant transfer and prioritizes the mother's consent, making it the safest option.
B. While checking identification is important, it does not establish proper protocol for transferring the infant and may not address whether the mother has authorized the transfer.
C. Allowing the grandmother to carry the grandchild without confirming the mother's wishes could lead to security and safety concerns, making this response inappropriate.
D. Allowing the grandmother to push the baby in a wheeled bassinet is not the standard practice; the nurse should ensure that the baby is safely transported by hospital staff.
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