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 A
Explanation
The correct answer is choice A.Washing hands before and after handling the cord stump can prevent the transmission of bacteria that can cause omphalitis, sepsis, and tetanus.
Choice B is wrong because applying petroleum jelly or ointment to the cord stump can delay its drying and increase the risk of infection.
Choice C is wrong because using hydrogen peroxide to clean the cord stump can damage the healthy tissue and delay healing.
Choice D is wrong because folding down the diaper below the cord stump can expose it to urine and feces, which can contaminate it and cause infection.
The normal range for umbilical cord separation is 5 to 15 days after birth.
Correct Answer is C
Explanation
The correct answer is choice C. Document this as a normal finding.According to the American Academy of Family Physicians, bleeding from the dorsal slit after circumcision using a Gomco clamp is usually minimal and will stop once the clamp is in place.
Therefore, a small amount of blood on the diaper 12 hours after the procedure is not a cause for concern and does not require any intervention.
Choice A is wrong because applying gentle pressure to stop bleeding is not necessary and may cause more trauma to the wound.
Choice B is wrong because changing the diaper more frequently may also disturb the healing process and increase the risk of infection.Choice D is wrong because notifying the physician is not indicated unless there is excessive or persistent bleeding, signs of infection, or other complications.
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