A nurse is caring for a newborn 8 hours old.
Axillary temperature: 37.1°C (96.8°F). Heart rate: 132/min.
Respiratory rate: 52/min.
At 36 hours of age: Axillary temperature: 36.1°C (97°F). Heart rate: 160/min.
Respiratory rate: 78/min.
Which of the following assessment findings require follow-up by the nurse?
lowing assessment findings require follow-up by the nurse?
Axillary temperature 36.1°C (97°F).
Respiratory rate 78/min.
Nasal flaring present.
Fontanel level and soft with large ecchymotic tinge.
Correct Answer : B,C,D
Choice A rationale
Axillary temperature of 36.1°C (97°F) is within the normal range for a newborn. It does not necessarily indicate a problem that requires follow-up. Temperature regulation in newborns can vary, and this value is not concerning.
Choice B rationale
Respiratory rate of 78/min is higher than the normal range for newborns (30-60 breaths per minute). This could indicate respiratory distress and requires follow-up to determine the underlying cause.
Choice C rationale
Nasal flaring is a sign of respiratory distress in newborns. It indicates that the baby is having difficulty breathing and requires immediate follow-up to assess the severity and provide appropriate interventions.
Choice D rationale
A fontanel that is level and soft with a large ecchymotic tinge could indicate bruising or trauma. This finding is unusual and requires follow-up to determine the cause and ensure there is no underlying issue that needs to be addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
If the client and the newborn are both Rh positive, Rh immunoglobulin is not necessary because there is no Rh incompatibility.
Choice B rationale
Rh immunoglobulin is administered when the mother is Rh negative and the newborn is Rh positive to prevent the mother's immune system from developing antibodies against Rh-positive blood.
Choice C rationale
If the client is Rh positive and the newborn is Rh negative, Rh immunoglobulin is not needed because Rh incompatibility does not occur in this scenario.
Choice D rationale
If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, so Rh immunoglobulin is not needed.
Correct Answer is D
Explanation
Choice A rationale
Platelets at 140,000 mg are within the normal range and are not typically indicative of postpartum complications like a thrombus.
Choice B rationale
Hemoglobin at 7 mg/dl indicates anemia but is not directly related to the symptoms of pain and tenderness in the calf.
Choice C rationale
A WBC count of 15,000 could indicate an infection or inflammatory process but is not specific to deep vein thrombosis (DVT).
Choice D rationale
Fibrinogen at 600 mg/dl is elevated and can be a marker for increased coagulation activity, which is associated with an increased risk of thrombosis. .
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