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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Current guidelines recommend that women aged 21 to 29 have a Pap test every three years, and those aged 30 to 65 can either have a Pap test every three years or a Pap plus HPV (human papillomavirus) test every five years. After age 65, and with a history of normal results, Pap tests may be discontinued.
Choice B rationale:
The nurse should not include choice B, "Pap tests are discontinued following removal of the ovaries,” in the teaching. The presence or absence of ovaries does not affect the need for Pap testing. The Pap test is primarily used to screen for cervical cancer, and its necessity is determined based on age and previous screening results, not on ovarian status.
Choice C rationale:
Patients are advised to avoid sexual intercourse, douching, or using vaginal medications for 24 hours before the test to ensure accurate results.
Choice D rationale:
The nurse should not include choice D, "Viral infections can be detected by a Pap test,” in the teaching. The Pap test is not designed to detect viral infections. Instead, it is used to detect abnormal cervical cells, which may indicate pre-cancerous or cancerous changes.
Correct Answer is D
Explanation
Choice A reason:
"Retract the foreskin until you feel resistance." This advice is not recommended for newborns with an uncircumcised penis. The foreskin of most male babies doesn't yet pull back (retract) fully at birth, and forcing it back can cause pain, bleeding, and possible damage.
Choice B reason:
"Use a cotton swab to clean under the foreskin." This is not advisable for a newborn's uncircumcised penis. The foreskin is usually still attached to the glans and does not require any special cleaning inside. Using a cotton swab could potentially cause harm by forcing the foreskin back.
Choice C reason:
"Apply petroleum jelly to the foreskin." This instruction is more applicable to a circumcised penis during the healing process to prevent the penis from sticking to the diaper. For an uncircumcised penis, there's no need to apply petroleum jelly as part of regular care.
Choice D reason:
"Wash the penis once per day with soap and water." This is the correct care for an uncircumcised penis. Parents should gently wash the genital area with mild soap and water during bath time without retracting the foreskin.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
