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 ["B","D"]
Explanation
Choice A rationale
Nonsteroidal anti-inflammatory drugs (NSAIDs) primarily exert their therapeutic effects through the inhibition of cyclooxygenase (COX) enzymes, thereby reducing prostaglandin synthesis. While they possess analgesic and anti-inflammatory properties that can alleviate pain and swelling associated with thrombophlebitis, NSAIDs do not directly prevent the formation of thrombi or address the underlying coagulopathy. Therefore, their administration is not a primary prophylactic measure against thrombophlebitis development.
Choice B rationale
Early and frequent ambulation promotes venous return by stimulating the calf muscle pump, which compresses deep veins and propels blood back towards the heart. This mechanical action counteracts venous stasis, a major component of Virchow's triad for thrombus formation. By maintaining blood flow velocity and preventing pooling in the lower extremities, ambulation significantly reduces the risk of deep vein thrombosis and subsequent thrombophlebitis.
Choice C rationale
Applying warm, moist packs to the lower legs can provide symptomatic relief by promoting vasodilation and improving local circulation, which may reduce pain and inflammation associated with existing thrombophlebitis. However, this intervention does not prevent the initial formation of a thrombus. In fact, vasodilation could theoretically increase blood flow to an area with an active clot, but it does not address the fundamental mechanisms of thrombogenesis, such as stasis or hypercoagulability.
Choice D rationale
Elastic stockings apply external graduated compression to the lower extremities, with the highest pressure at the ankle and gradually decreasing pressure proximally. This external pressure helps to reduce venous distention, increase venous blood flow velocity, and prevent the pooling of blood in the superficial and deep veins. By mitigating venous stasis, a critical factor in the pathogenesis of thrombophlebitis, elastic stockings effectively reduce the risk of thrombus formation.
Correct Answer is D
Explanation
Choice A rationale
Long-grain rice is primarily a source of carbohydrates, providing energy, but contains negligible amounts of calcium. While it is a healthy staple, it does not contribute significantly to meeting the increased calcium requirements during pregnancy, which are essential for fetal bone development and maintaining maternal bone density.
Choice B rationale
Peanut butter is a good source of protein, healthy fats, and some vitamins and minerals like magnesium and potassium. However, its calcium content is relatively low compared to dairy products or fortified foods. Relying on peanut butter alone would not be an efficient way to address a low calcium level during pregnancy.
Choice C rationale
Avocados are rich in healthy monounsaturated fats, fiber, and various vitamins such as K, C, E, and B-6, as well as folate. While highly nutritious, avocados contain only a modest amount of calcium and are not considered a primary source for addressing calcium deficiency in pregnancy.
Choice D rationale
Yogurt is an excellent source of calcium, providing a bioavailable form of this essential mineral, crucial for bone health and numerous physiological processes. A single serving of plain yogurt can provide approximately 300-450 mg of calcium, making it a highly recommended food to increase dietary calcium intake during pregnancy.
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