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
Applying hot compresses to the breasts prior to feeding is not recommended for painful nipples due to breastfeeding. It may exacerbate pain and discomfort.
Choice B rationale
Teaching latching and releasing of suction techniques helps ensure that the baby latches correctly and releases properly from the breast, which can prevent and alleviate nipple pain and trauma.
Choice C rationale
Rubbing colostrum on the nipples after a feeding session is beneficial as colostrum has healing properties, but it does not address the immediate technique-related cause of painful nipples.
Choice D rationale
Air-drying nipples for 10 minutes at the end of the feeding session can be helpful for healing, but proper latching techniques are more effective in preventing nipple pain.
Correct Answer is F
Explanation
Choice A rationale
Stools are a normal occurrence in newborns and are not typically associated with significant complications. The frequency and consistency can vary, but abnormal stools would not explain the given vital signs.
Choice B rationale
Temperature control is vital in newborns, but the given temperature is slightly low and alone does not indicate a specific complication without additional context such as infection or environment.
Choice C rationale
Feeding difficulties can occur in newborns, but they would typically present with symptoms related to weight and growth rather than the specific vital signs provided.
Choice D rationale
Extremities’ conditions, such as cyanosis or poor circulation, could indicate complications, but the given vital signs are not directly indicative of extremity problems.
Choice E rationale
Hypoglycemia in newborns can present with signs like jitteriness or lethargy, but it does not directly correlate with the provided vital signs without additional glucose measurements.
Choice F rationale
Neonatal Abstinence Syndrome (NAS) includes symptoms such as high heart rate, respiratory rate, and temperature instability, which align with the newborn's vital signs.
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