A nurse is assessing a newborn’s vital signs at 1 hour of age.
Which of the following findings should the nurse report to the provider?
Heart rate of 140/min
Respiratory rate of 50/min
Temperature of 36°C (96.8°F)
Blood pressure of 60/40 mm Hg
The Correct Answer is C
The correct answer is choice C. A temperature of 36°C (96.8°F) is below the normal range for a newborn, which is 36.5°C to 37.5°C (97.7°F to 99.5°F).
A low temperature can indicate hypothermia, infection, or hypoglycemia, and should be reported to the provider.
Choice A is wrong because a heart rate of 140/min is within the normal range for a newborn, which is 120 to 160/min.
Choice B is wrong because a respiratory rate of 50/min is within the normal range for a newborn, which is 30 to 60/min.
Choice D is wrong because a blood pressure of 60/40 mm Hg is within the normal range for a newborn, which is 50 to 75/30 to 45 mm Hg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Check if there is any cross-sensitivity between erythromycin and penicillin.Erythromycin is a macrolide antibiotic that can be used to treat bacterial eye infections in newborns and adults.
Penicillin is a beta-lactam antibiotic that can cause allergic reactions in some people.
Cross-sensitivity means that a person who is allergic to one type of antibiotic may also be allergic to another type of antibiotic that has a similar structure or mechanism of action.Erythromycin and penicillin have different structures and mechanisms of action, but there is still a small chance of cross-sensitivity between them.
Therefore, the nurse should check if the newborn has any history of allergic reaction to penicillin before applying the erythromycin eye ointment.
Choice A is wrong because asking the mother if she has any allergies to antibiotics is not enough to determine if the newborn is at risk of an allergic reaction to erythromycin.
The newborn may have inherited or developed an allergy to penicillin or erythromycin that the mother does not have.
Choice C is wrong because applying a small amount of ointment on the skin to test for allergic reaction is not a reliable method to diagnose an allergy.Skin testing can cause false positive or false negative results, and it may also trigger a severe allergic reaction in some cases.
Choice D is wrong because administering an antihistamine to prevent anaphylaxis is not appropriate for a newborn who has not been exposed to the allergen yet.
An antihistamine is a medication that blocks the effects of histamine, a chemical that causes allergic symptoms.
Anaphylaxis is a life-threatening allergic reaction that involves multiple organ systems and requires immediate medical attention.An antihistamine cannot prevent anaphylaxis, and it may also cause side effects such as drowsiness, dry mouth, or low blood pressure in a newborn.
Correct Answer is ["A","C","D","E"]
Explanation
The correct answer is choice A, C, D, and E.Hypoglycemia due to perinatal asphyxia can cause various neurological signs in the newborn, such as irregular respirations, apnea, eye-rolling, and lethargy.
These signs indicate inadequate oxygenation and glucose delivery to the brain.Cyanosis is not a specific sign of hypoglycemia, but rather a sign of poor oxygenation that can occur due to other causes.
Therefore, choice B is wrong.
Choice A is correct because irregular respirations can result from hypoglycemia due to perinatal asphyxia.Hypoglycemia can impair the respiratory center in the brainstem and cause irregular breathing patterns.
Choice C is correct because apnea can result from hypoglycemia due to perinatal asphyxia.
Apnea is defined as a pause in breathing
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