A nurse is collecting data from a newborn who is 4 hours old.
Which of the following findings should the nurse report to the provider?
Respiratory rate 24/min.
Heart rate 150/min.
Blood pressure 82/44 mm Hg.
Temperature 37.2° C (99° F).
The Correct Answer is A
Choice A rationale
A respiratory rate of 24 breaths/min in a 4-hour-old newborn is below the normal range, which is typically between 30 and 60 breaths/min. A rate this low could indicate respiratory depression or distress, requiring immediate assessment and intervention by the healthcare provider to ensure adequate oxygenation.
Choice B rationale
A heart rate of 150 beats/min is within the normal physiological range for a newborn, which typically falls between 110 and 160 beats/min. This rate reflects the newborn's circulatory adaptation to extrauterine life and is not a cause for concern in an otherwise stable infant.
Choice C rationale
A blood pressure of 82/44 mm Hg is within the normal range for a term newborn. Normal systolic blood pressure in a newborn is generally between 60-90 mm Hg, and diastolic blood pressure is typically between 30-60 mm Hg, reflecting healthy cardiovascular function and systemic perfusion.
Choice D rationale
A temperature of 37.2° C (99° F) is within the normal range for a newborn's body temperature. The normal axillary temperature for a newborn is typically between 36.5° C and 37.5° C (97.7° F and 99.5° F), indicating appropriate thermoregulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Transcutaneous electrical nerve stimulation (TENS) is primarily used during the first and second stages of labor to manage discomfort by interfering with pain signal transmission through nerve stimulation. Its effectiveness significantly diminishes in the third stage, which involves the expulsion of the placenta, as the pain sensation during this stage is distinct and less responsive to superficial nerve modulation.
Choice B rationale
Gestational diabetes itself is not a contraindication for TENS use. TENS therapy works by stimulating sensory nerves to block pain signals or release endorphins. The metabolic changes associated with gestational diabetes do not interfere with the biophysical mechanisms by which TENS alleviates pain, making it a safe option for pain management in this population.
Choice C rationale
Increasing TENS intensity during a contraction aligns with the physiological response to labor pain. As uterine contractions intensify, the perceived pain increases. Manually adjusting the TENS unit's intensity during a contraction allows for a dynamic and responsive pain management strategy, providing greater counter-stimulation when the pain is at its peak, enhancing its efficacy.
Choice D rationale
TENS does not eliminate pain during a contraction but rather reduces its perception. It works by activating large diameter afferent nerve fibers, which inhibits the transmission of nociceptive signals via the gate control theory of pain. It also may stimulate the release of endogenous opioids, modulating pain pathways, leading to a reduction in pain intensity, not complete abolition.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}
Explanation
? Rationales for Each Condition
1️⃣ Neonatal abstinence syndrome (NAS)
Definition: NAS is a withdrawal syndrome in newborns caused by in utero exposure to opioids or other substances. It typically presents within 24–72 hours after birth.
Findings and Scientific Explanation:
- Cry characteristics: A high-pitched, inconsolable cry is a hallmark of NAS due to autonomic nervous system dysregulation.
- Nasal findings: Sneezing and nasal stuffiness are common due to increased autonomic activity and are not typically seen in hypoglycemia.
- Tremor: Tremors, especially when undisturbed, are due to central nervous system irritability from opioid withdrawal.
- Maternal urine drug screen: A positive result for opioids confirms in utero exposure, supporting a diagnosis of NAS.
- Respiratory rate: Tachypnea (e.g., 65/min on Day 3) is common in NAS due to increased metabolic demand and autonomic instability. Normal neonatal respiratory rate is 30–60/min.
2️⃣ Hypoglycemia
Definition: Neonatal hypoglycemia is defined as a plasma glucose concentration less than 40–45 mg/dL in the first 24 hours of life.
Findings and Scientific Explanation:
- Cry characteristics: Hypoglycemia may cause irritability or weak cry due to neuroglycopenia.
- Tremor: Tremors or jitteriness can result from adrenergic stimulation in response to low glucose levels.
- Respiratory rate: Tachypnea may occur as a compensatory response to metabolic acidosis secondary to hypoglycemia. The newborn had a glucose of 35 mg/dL on Day 1, which is below the normal range (>40–45 mg/dL).
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