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
One of the most important interventions in caring for clients with major depressive disorder is building a therapeutic relationship. Scheduling regular periods of time for interaction with the client demonstrates support and provides an opportunity for the client to express their feelings and concerns. Journaling and self-reflection can be helpful interventions for some clients, but they do not necessarily demonstrate support.
Assisting the client to identify symptoms of depression is important for assessment and care planning, but it is not a way to demonstrate support.
Incorporating animated communication techniques may be appropriate for certain clients, but it is not a universal intervention for supporting clients with major depressive disorder.
Correct Answer is D
Explanation
Fetal heart rate (FHR) is one of the essential indicators of fetal well-being during labor. A fall in FHR following each contraction is known as recurrent deceleration and can be an indication of fetal distress. In this case, the PN should first reposition the client laterally, as this may help to alleviate compression of the umbilical cord and improve fetal oxygenation.
A. Administering oxygen at 10 L/face mask may be necessary, but it is not the first intervention to be implemented in this scenario.
B. Discontinuing oxytocin infusion may be necessary, but it is not the first intervention to be implemented in this scenario.
C. Observing perineum for cord prolapse is not necessary in this scenario.
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