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 A
Explanation
Fresh cabbage leaves have been traditionally used as a home remedy to help alleviate pain and discomfort associated with breast engorgement. The coolness of the cabbage leaves can provide a soothing effect, and they may also have anti-inflammatory properties that help reduce swelling. However, it is important to note that this should be used as a complementary measure and not a substitute for medical treatment or advice if the engorgement is severe or persistent.
Correct Answer is D
Explanation
Choice A rationale:
Decreasing fiber intake is not a recommended action for urinary incontinence. Fiber intake is related to bowel health and does not directly affect urinary incontinence.
Choice B rationale:
Avoiding Kegel exercises is not recommended for urinary incontinence. Kegel exercises are beneficial for strengthening the pelvic floor muscles, which can help improve urinary continence.
Choice C rationale:
Restricting fluid intake to 1 liter per day is not advisable for urinary incontinence. Adequate hydration is essential for overall health, and limiting fluid intake can lead to dehydration and other health issues.
Choice D rationale:
Reducing intake of caffeinated and carbonated beverages is a helpful recommendation for a client experiencing urinary incontinence. Caffeine and carbonation can irritate the bladder and worsen incontinence symptoms.
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