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
This can offer a safe place for her and her unborn child. The shelter can also provide resources for counseling and legal assistance if needed.
The safety plan and restraining order are important measures, but the priority should be to ensure the client's immediate safety.
The visit summary documenting the report of abuse is also important, but it should not be the only information provided to the client.
Correct Answer is C
Explanation
Phyto menadione injectable, also known as vitamin K1, is commonly given to newborns to prevent hemorrhagic disease of the newborn (HDN), a bleeding disorder that can occur due to vitamin K deficiency in the first few days of life. Vitamin K is important for the production of clotting factors in the liver, and newborns are at risk of vitamin K deficiency because it does not cross the placenta well and their intestinal flora is not yet established. The other options do not accurately describe the purpose of administering Phyto menadione injectable to newborns.
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