A nurse is completing the admission assessment of a newborn.
Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?

Xiphoid process.

Fifth intercostal space.

Sternal notch.

Nipple line.

Answer and Explanation

The Correct Answer is D

Choice A rationale

The xiphoid process is not the correct anatomical landmark for measuring chest circumference in newborns. It is located at the lower end of the sternum and does not provide a consistent measurement point.

Choice B rationale

The fifth intercostal space is not used for measuring chest circumference in newborns. This space is located between the ribs and is not a reliable landmark for consistent measurements.

Choice C rationale

The sternal notch is not the correct landmark for measuring chest circumference. It is located at the top of the sternum and does not provide a consistent measurement point.

Choice D rationale

The nipple line is the correct anatomical landmark for measuring chest circumference in newborns. This method ensures that the measurement is taken at a consistent and reproducible location, providing an accurate assessment of the chest size relative to growth and development standards.

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Correct Answer is D

Explanation

Choice A rationale

An apical pulse rate of 124 bpm is within the normal range for a neonate (110-160 bpm). There is no need to ask another nurse to verify the heart rate as it is not an abnormal finding.

Choice B rationale

Calling the provider for an apical pulse rate of 124 bpm is unnecessary as it is within the normal range for a neonate. This action would be appropriate if the heart rate were significantly outside the normal range.

Choice C rationale

Preparing the newborn for transport to the NICU for an apical pulse rate of 124 bpm is not warranted. The heart rate is within the normal range, and there is no indication for further cardiac observation.

Choice D rationale

Documenting the expected finding is the appropriate action. An apical pulse rate of 124 bpm is within the normal range for a neonate, and no further action is needed.

A. Sucking on their fingers. B. Smacking their lips. C. Extending their tongue. D. Crying. E. Rooting.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale

Sucking on their fingers is an early hunger cue in infants. It indicates that the baby is ready to feed.

Choice B rationale

Smacking their lips is another early hunger cue. It shows that the baby is thinking about feeding.

Choice C rationale

Extending their tongue is also an early hunger cue. It indicates that the baby is ready to latch onto the breast or bottle.

Choice D rationale

Crying is a late hunger cue. It is better to feed the baby before they start crying to make feeding easier.

Choice E rationale

Rooting is an early hunger cue. It involves the baby turning their head towards the breast or bottle, indicating they are ready to feed. .

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A nurse is completing the admission assessment of a newborn.Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursery nurse is admitting a neonate and is performing the neonatal assessment.The apical pulse is auscultated with a rate of 124 bpm, after one full minute of listening.What is the next appropriate action should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is ["A","B","C","E"]

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A nurse is completing the admission assessment of a newborn.
Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?