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 A
Explanation
Choice A rationale:
Placing the newborn in an incubator is essential because the newborn's temperature control mechanism is immature. Premature infants have an underdeveloped thermoregulatory system, making them susceptible to heat loss and cold stress. An incubator provides a controlled, warm environment to maintain the newborn's body temperature within the normal range (around 36.5°C to 37.5°C or 97.7°F to 99.5°F).
Choice B rationale:
Heat increasing the flow of oxygen to the newborn's extremities is not a valid reason for placing the newborn in an incubator. Oxygenation is primarily influenced by respiratory and circulatory mechanisms, not external heat.
Choice C rationale:
The newborn's small body surface area for his weight is not directly related to the need for an incubator. Premature infants have a higher surface area to weight ratio, making them more prone to heat loss, but this is not the primary reason for using an incubator.
Choice D rationale:
Heat facilitating the drainage of mucus is not a reason for placing the newborn in an incubator. Proper positioning and suctioning are used to manage mucus in premature infants, but incubators are primarily for temperature regulation.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
Drying the baby thoroughly is not directly related to assessing the successful transition of the respiratory system. It is essential for warmth and comfort but does not provide specific information about the respiratory system.
Choice B rationale:
Suctioning the mouth and nose with a bulb syringe to clear mucus is important to ensure the airways are clear and the newborn can breathe effectively. This action helps assess the airway patency and successful initiation of breathing.
Choice C rationale:
Observing the chest and abdomen is crucial to assess the respiratory effort and symmetry. Normal chest movements and equal rise and fall of the abdomen indicate a successful transition of the respiratory system.
Choice D rationale:
Counting the number of respirations per minute is essential to determine if the respiratory rate falls within the expected reference range (around 30-60 breaths per minute for a newborn) and if there are any irregularities.
Choice E rationale:
Observing the color of the mucous membranes is important as cyanosis (blue discoloration) may indicate inadequate oxygenation. Pink mucous membranes are a positive sign, indicating a successful transition of the respiratory system.
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