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:
The correct guidance includes giving the newborn sponge baths until the cord stump falls off, which helps to keep the area dry. It is essential to keep the umbilical cord stump clean and dry to prevent infection. Submerging the cord stump in water could increase the risk of infection.
Choice B rationale:
Covering the cord with the diaper is not advisable. The diaper could trap moisture around the cord stump, leading to a higher risk of infection. The cord stump should be exposed to air as much as possible to aid in drying and healing.
Choice C rationale:
Washing the cord with mild soap and water is not necessary and could introduce moisture, which should be avoided. Instead, the stump should be cleaned gently with a soft, dry cloth if it gets dirty.
Choice D rationale:
Wrapping the cord in petroleum jelly gauze is not a recommended practice. Applying petroleum jelly or other substances to the cord stump can interfere with the drying process and increase the risk of bacterial growth, leading to infection.
Correct Answer is A
Explanation
"My baby will be placed under special lights if the test is elevated.”.
Choice A rationale:
This statement indicates a need for further teaching. Phenylketonuria (PKU) is a metabolic disorder that leads to the accumulation of phenylalanine in the body. If the PKU test is elevated, it means that the baby has high levels of phenylalanine, and immediate dietary intervention is required. The parent's statement about special lights suggests a confusion with jaundice treatment, which is not related to PKU.
Choice B rationale:
This statement is accurate. Before the PKU test is done, the baby needs to consume formula or breast milk to ensure accurate test results.
Choice C rationale:
This statement is also accurate. PKU is a genetic disorder that can be managed with a special diet low in phenylalanine. By adhering to the prescribed diet, the harmful effects of PKU can be minimized.
Choice D rationale:
This statement is accurate. It is common for the PKU test to be repeated at the 2-week check- up to confirm the initial results and ensure early detection and management of PKU if present.
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