Rh: Positive. Action to Take 1: Obtain a transcutaneous bilirubin level. Action to Take 2: Administer methadone. Actions to Take: Monitor platelet count. Place the newborn under a radiant warmer. Check the newborn's capillary blood glucose level. Potential Conditions: Hyperbilirubinemia. Cytomegalovirus infection. Hypoglycemia. Neonatal abstinence syndrome. Parameters to Monitor 1: Temperature. Parameter to Monitor 2: Color and of bowel movements. Seizure activity. Frequent yawning. Petechiae. Respiratory rate: 68/min auscultation. Temperature: 36.1°C (96.9°F) axillary. Action to Take 1: Obtain a transcutaneous bilirubin level. Action to Take 2: Administer methadone. Actions to Take: Monitor platelet count. Place the newborn under a radiant warmer. Check the newborn's capillary blood glucose level. Potential Conditions: Hyperbilirubinemia. Cytomegalovirus infection.
Hypoglycemia. Neonatal abstinence syndrome. Parameters to Monitor 1: Temperature. Parameter to Monitor 2: Color and of bowel movements. Seizure activity. Frequent yawning.
Petechiae. Exhibit 1. What are the newborn vital sign ranges? Select all that apply. (Select All that Apply).
Temperature 97.7-99.3 axillary.
Heart rate asleep 100 bpm, 120-160 bpm, crying: 180 bpm.
Blood pressure not routinely assessed.
Respiratory rate 30-60 breaths per minute.
Correct Answer : A,B,D
Choice A rationale:
The normal temperature range for a newborn measured axillary (armpit) is 97.7-99.3°F (36.5- 37.4°C). This is a crucial vital sign to monitor, as any significant deviation from this range could indicate an underlying issue requiring further evaluation.
Choice B rationale:
The newborn's heart rate varies with their activity level. While asleep, it is around 100 bpm, and when awake, it is 120-160 bpm. During crying or agitation, it can go up to 180 bpm.
Monitoring the heart rate is essential, as any abnormal values might indicate cardiac or other health problems.
Choice D rationale:
The normal respiratory rate for a newborn is 30-60 breaths per minute. Respiratory rate is a critical parameter to monitor as rapid or slow breathing could be a sign of respiratory distress or other respiratory conditions.
Choice C rationale:
Blood pressure is not routinely assessed in newborns, as it is challenging to obtain accurate readings due to their small size and physiology. Instead, other vital signs are relied upon for assessment.
Choice E rationale:
The head circumference is not included in the normal vital sign ranges. However, monitoring head circumference is crucial during infancy to track brain growth and development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Pseudomenstration is a normal finding in newborn females due to the withdrawal of maternal hormones. It is not a cause for concern and typically resolves within a few days after birth.
Choice B rationale:
Positive Ortolan's test is a concerning finding in a newborn and indicates the possibility of developmental dysplasia of the hip (DDH). This test is used to check for hip instability, and a positive result may warrant further evaluation and intervention to prevent long-term hip problems.
Choice C rationale:
Dermal melanosis, also known as Mongolian spots, is a common benign condition in newborns with dark skin. It appears as blue or gray patches and typically fades within the first few years of life. While it may be alarming to parents, it is not a cause for immediate concern.
Choice D rationale:
Gynecomastia, the enlargement of breast tissue in male infants, is relatively common and is caused by the transfer of maternal hormones during pregnancy. It usually resolves on its own within a few weeks and does not pose a significant health risk.
Correct Answer is C
Explanation
Choice A rationale:
Applying crushed cabbage leaves to the breasts can be a traditional remedy to help reduce swelling and discomfort associated with engorgement.
Choice B rationale:
Wearing a snug-fitting bra can help provide support to the breasts and reduce discomfort from breast engorgement. It can also help to avoid stimulation of the breasts, which can decrease milk production in a client who is not breastfeeding. This is an appropriate comfort measure for the client.
Choice C rationale:
Stimulating the nipples by squeezing softly can lead to increased milk production and exacerbate breast engorgement. For a client who is not breastfeeding, this action is not recommended and may worsen the engorgement.
Choice D rationale:
Applying ice packs to the breasts can help reduce inflammation and alleviate discomfort from breast engorgement. This is an appropriate comfort measure for the client who is not breastfeeding.
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