A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?
Axillary temperature 36.5°C (97.7°F).
Nasal flaring.
Heart rate 158/min.
One void since birth.
The Correct Answer is B
Choice A rationale:
An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. Normal axillary temperature for a newborn is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice B rationale:
This is the correct choice. Nasal flaring in a newborn is a concerning sign and may indicate respiratory distress. It suggests that the baby is having difficulty breathing and should be reported to the provider for further evaluation.
Choice C rationale:
A heart rate of 158/min is within the normal range for a newborn. The normal heart rate for a newborn can range from 100 to 160 beats per minute.
Choice D rationale:
Having one void since birth is not a concerning finding for a 10-hour-old newborn. In the early hours of life, the frequency of voids may vary, but the baby should have an increasing number of wet diapers in the following days.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hormonal changes play a significant role in postpartum depression. After childbirth, there is a rapid decline in estrogen and progesterone levels, which can lead to mood fluctuations and depressive symptoms. Understanding this hormonal aspect is crucial for the nurse to address postpartum depression risk factors.
Choice B rationale:
Increased social support systems would be considered a protective factor against postpartum depression rather than a risk factor. Having strong social support can help mitigate the risk of developing postpartum depression.
Choice C rationale:
High self-esteem is not typically a risk factor for postpartum depression. In fact, individuals with higher self-esteem may be more resilient in coping with the challenges of postpartum period.
Choice D rationale:
Being a mother of two other children is not inherently a risk factor for postpartum depression. While having multiple children can be demanding, it does not directly increase the risk of developing postpartum depression. The hormonal changes and individual circumstances play more significant roles.
Correct Answer is A
Explanation
Choice A rationale:
This finding may indicate a neurological problem or an issue with the baby's ability to feed, which can lead to inadequate nutrition and hydration. It's essential for the newborn to establish good feeding patterns early on
Choice B rationale:
Blue coloring of the hands and feet, also known as acrocyanosis, is a common and normal finding in newborns. It results from the immaturity of the peripheral circulation and usually resolves on its own without any intervention.
Choice C rationale:
A soft, edematous area on the scalp, also known as caput succedaneum, is a common finding following vacuum-assisted delivery and typically resolves without intervention.
Choice D rationale:
Facial edema is another common finding in newborns, especially after vacuum-assisted deliveries. It is typically a transient and self-resolving condition that does not require immediate intervention or reporting to the provider.
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