When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?
Hypothermia.
Deficient fluid volume.
Impaired gas exchange.
Risk for infection.
The Correct Answer is A
Choice A reason:
Hypothermia is the priority area for this newborn because the axillary temperature of 95.8° F (35.4° C) is below the normal range of 97.7° F to 99.5° F (36.5° C to 37.5° C) for newborns1. Hypothermia can lead to complications such as hypoglycemia, metabolic acidosis, and impaired oxygen delivery2. The nurse should initiate interventions to warm the newborn, such as skin-to-skin contact, radiant warmer, or swaddling2.
Choice B reason:
Deficient fluid volume is not the priority area for this newborn because the apical pulse of 114 beats per minute is within the normal range of 100 to 160 beats per minute for newborns345. A low pulse rate can indicate dehydration or shock in newborns2. The nurse should monitor the newborn's fluid intake and output, weight, and signs of dehydration, such as dry mucous membranes, sunken fontanels, and poor skin turgor2.
Choice C reason:
Impaired gas exchange is not the priority area for this newborn because the respiratory rate of 60 breaths per minute is within the normal range of 30 to 60 breaths per minute for newborns345. A high or low respiratory rate can indicate respiratory distress or failure in newborns2. The nurse should assess the newborn's breath sounds, chest movements, oxygen saturation, and signs of respiratory distress, such as nasal flaring, grunting, retractions, and cyanosis2.
Choice D reason:
Risk for infection is not the priority area for this newborn because there is no evidence of infection in the vital signs or the question stem. However, newborns are vulnerable to infection due to their immature immune systems and exposure to pathogens during birth and aftercare2. The nurse should follow infection control measures, such as hand hygiene, aseptic technique, and cord care, and educate the parents on how to prevent infection at home2.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
10% to 15% of their birth weight. This is incorrect because this range is too high for a normal newborn weight loss. Losing more than 10% of their birth weight may indicate dehydration, inadequate feeding, or other problems. • Choice B reason:
20% of their birth weight. This is incorrect because this percentage is way too high for a normal newborn weight loss. Losing 20% of their birth weight would be a serious sign of illness or malnutrition. • Choice C reason:
15% to 18% of their birth weight. This is incorrect because this range is also too high for a normal newborn weight loss. Losing 15% to 18% of their birth weight would be a cause for concern and require further evaluation. • Choice D reason:
5% to 10% of their birth weight. This is correct because this range is within the normal limits for a newborn weight loss. Newborns lose some weight as a result of insufficient caloric intake, fluid loss, and metabolic adjustments in the first week after birth. They usually regain their birth weight by the second week.
Correct Answer is B
No explanation
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