Which newborn assessment finding of 24-hour-old infant should the practical nurse (PN) report to the charge nurse immediately?
Weight loss of 4 ounces since birth.
Respiratory rate of 55 breaths/minute.
Axillary temperature of 97.6° F (36.4° C).
Heart rate of 100 beats/minute.
The Correct Answer is D
The newborn assessment finding that the practical nurse (PN) should report to the charge nurse immediately for a 24-hour-old infant is a heart rate of 100 beats/minute. The normal heart rate for a newborn is between 120-160 beats/minute. A heart rate of 100 beats/minute is below the normal range and may indicate a problem such as hypothermia or an infection. The PN should report this finding to the charge nurse immediately so that appropriate action can be taken to address the issue. The other assessment findings listed may also be important to monitor, but a heart rate of 100 beats/minute is the most urgent and requires immediate attention.
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Related Questions
Correct Answer is A
Explanation
Respiratory syncytial virus (RSV) is a highly contagious virus that can cause severe respiratory infections, especially in infants and young children. RSV is easily spread through contact with respiratory secretions from infected individuals, and can survive on surfaces for several hours. Therefore, it is important to avoid exposing other children to RSV, especially those who are under 6 months old or have a weakened immune system. The practical nurse (PN) should advise the mother not to take her infant to the birthday party to prevent the spread of RSV to other children. The PN can provide education on how to prevent the spread of RSV, such as washing hands frequently, avoiding close contact with sick individuals, and covering the mouth and nose when coughing or sneezing.
Correct Answer is C
Explanation
Restlessness, confusion, and agitation are common symptoms of dementia, particularly in the evening, a phenomenon known as sundowning. Therefore, the PN should implement interventions that can help to prevent or minimize these symptoms. Assigning the client to a room close to the nurses' station can help to provide constant observation and reassurance and can help to prevent the client from wandering or becoming disoriented.
A. Delaying administration of nighttime medications until after visitors have left may be appropriate, but it is not the first intervention to be implemented in this scenario.
B. Administering a prescribed PRN benzodiazepine at the onset of a confused state may be appropriate in some cases, but it should not be the first intervention to be implemented in this scenario.
D. Asking family members about how they dealt with the client in the evening may be helpful, but it is not the first intervention to be implemented in this scenario.
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