A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

110/min

100/min

22/min

48/min

Answer and Explanation

The Correct Answer is D

A.   A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
B.   A respiratory rate of 100/min is too high for a newborn and may indicate respiratory distress.
C. A respiratory rate of 22/min is too low for a newborn.
D.   A normal respiratory rate for a newborn is between 40 and 60 breaths per minute.

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Correct Answer is B

Explanation

A. This is not appropriate for the taking-in stage, as the woman may not be ready to absorb new information or focus on self-care. She may need more verbal instruction and demonstration from the nurse.
B. The taking-in stage is a period of passive, dependent behavior in which the woman reviews her childbirth experience and adjusts to the new role of motherhood. She may need to talk about her labor and delivery repeatedly and seek reassurance from others. The nurse should listen attentively and validate her feelings.
C. This is more suitable for the taking-hold stage, which occurs after the taking-in stage. In this stage, the woman becomes more active and independent, and shows interest in learning how to care for herself and her baby.
D. This is also more appropriate for the taking-hold stage, when the woman develops confidence and competence in her maternal role. In the taking-in stage, she may be more focused on her own needs and rely on others to care for the baby.

A. Document this as an expected finding. B. Call the provider to further assess the newborn. C. Prepare the newborn for transport to the NICU. D. Ask another nurse to verify the heart rate.

Correct Answer is A

Explanation

A. An apical heart rate of 130/min is within the normal range for a newborn and does not require immediate intervention.
B. Contacting the provider is not necessary as the heart rate is within the expected range.
C. Preparing for NICU transport is not warranted based on a heart rate of 130/min.
D. Verifying the heart rate with another nurse is unnecessary for a heart rate within the normal range.

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A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

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Naxlex Comprehensive Predictor Exams

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment after childbirth. Recognizing the needs of women during this stage, how should the nurse respond?

Correct Answer is B

Explanation

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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