A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?

Respiratory rate 55/min

Blood pressure 80/50 mm Hg

Temperature 36.5°C (97.7°F)

Heart rate 72/min

Answer and Explanation

The Correct Answer is D

Heart rate is one of the vital signs that reﬂects the health and well-being of a newborn. It is measured by counting the number of heart beats per minute, either by listening to the chest with a stethoscope or by feeling the pulse at the wrist, elbow, or groin. Heart rate can vary depending on the newborn's activity level, temperature, and emotional state¹.
The normal range for heart rate in full-term newborns is 120 to 160 beats per minute. The heart rate may be slightly higher or lower depending on the newborn's age, weight, and gestational age. For example, premature newborns may have a higher heart rate than term newborns, and heavier newborns may have a lower heart rate than lighter newborns¹².
A heart rate that is too high (tachycardia) or too low (bradycardia) can indicate a problem with the newborn's heart function, oxygenation, or circulation. Some of the possible causes of abnormal heart rate in newborns are:

-   Congenital heart defects: structural abnormalities of the heart that are present at birth and aﬀect the blood ﬂow through the heart and the body. They can cause cyanosis (bluish skin color), murmur (abnormal heart sound), poor feeding, or failure to thrive¹³.
-   Arrhythmias: irregular or abnormal heart rhythms that can aﬀect the electrical impulses that control the heartbeat. They can cause palpitations (feeling of skipped or extra beats), dizziness, fainting, or cardiac arrest¹³.
-   Hypoxia: lack of oxygen in the blood or tissues that can aﬀect the brain and other organs. It can be caused by respiratory distress, anemia, infection, or birth asphyxia. It can cause bradycardia, apnea (pauses in breathing), seizures, or coma¹⁴.
-   Hypothermia: low body temperature that can aﬀect the metabolism and organ function. It can be caused by exposure to cold environment, infection, or prematurity. It can cause bradycardia, lethargy, poor feeding, or hypoglycemia (low blood sugar)¹⁴.
-   Sepsis: severe infection that can aﬀect the whole body and cause inﬂammation and organ damage. It can be caused by bacteria, viruses, fungi, or parasites that enter the bloodstream from the mother, the umbilical cord, or the environment. It can cause tachycardia, fever, chills, poor feeding, or shock¹⁴.
Therefore, the nurse should report a heart rate of 72/min to the provider as an abnormal finding and monitor the newborn for any other signs of distress or illness. The provider may order further tests or treatments to determine the cause and severity of the low heart rate and prevent any complications.

The other findings are not findings that the nurse should report to the provider because they are within the
normal range for full-term newborns:
-   a) Respiratory rate 55/min is within the normal range for respiratory rate in full-term newborns. The normal range for respiratory rate in full-term newborns is 40 to 60 breaths per minute. The respiratory rate may vary depending on the newborn's activity level, temperature and emotional state¹².
-   b) Blood pressure 80/50 mm Hg is within the normal range for blood pressure in full-term newborns. The normal range for blood pressure in full-term newborns is 65 to 95 mm Hg for systolic pressure (the top number) and 30 to 60 mm Hg for diastolic pressure (the bottom number). The blood pressure may vary depending on the newborn's age, weight, and gestational age¹².
-   c) Temperature 36.5°C (97.7°F) is within the normal range for temperature in full-term newborns. The normal range for temperature in full-term newborns is 36.5°C to 37.5°C (97.7°F to 99.5°F). The temperature may vary depending on the newborn's activity level, clothing, and environment¹².

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Correct Answer is C

Explanation

Endometritis is an infection of the endometrium, the lining of the uterus, typically occurring after childbirth. When assessing a client with endometritis, the nurse should expect to find uterine tenderness as a common clinical finding. This finding is consistent with endometritis, which is characterized by inﬂammation and infection of the endometrium. Additional signs and symptoms may include an elevated temperature, increased lochia, foul-smelling lochia, and an elevated WBC count. Prompt identification and treatment of endometritis are important to prevent further complications.

Option a) A temperature of 37.4°C (99.3°F) is within the normal range and does not necessarily indicate endometritis. However, an elevated temperature above 38°C (100.4°F) or a persistent fever may be indicative of an infection and should be further evaluated.

Option b) Scant lochia (minimal vaginal bleeding) is not a characteristic finding of endometritis. In endometritis, lochia is often increased in amount and may have an unpleasant odor.

Option d) A white blood cell (WBC) count of 9,000/mm³ is within the normal range. However, in cases of endometritis, there is usually an elevation in the WBC count as a response to the infection. An elevated or increasing WBC count may be observed.

A. Swaddle the newborn with his legs extended. B. Maintain eye contact with the newborn during feedings. C. Schedule larger volume feedings at less frequent intervals. D. Plan care to minimize handling of the newborn.

Correct Answer is D

Explanation

Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to addictive substances, such as opioids, during pregnancy. Infants with NAS may experience withdrawal symptoms and can be hypersensitive to stimuli. Therefore, it is important to minimize unnecessary handling to help reduce stimulation and discomfort for the newborn.

Option a) Swaddling the newborn with his legs extended may increase discomfort for a newborn with NAS. It is often recommended to swaddle newborns with NAS in a ﬂexed position to provide a sense of security and comfort.

Option b) Maintaining eye contact during feedings may be overwhelming for a newborn with NAS. Maintaining a calm, quiet environment during feedings can help reduce overstimulation and improve feeding success.

Option c) Scheduling larger volume feedings at less frequent intervals may not be appropriate for a newborn with NAS. These infants may have poor feeding tolerance and may benefit from smaller, more frequent feedings to avoid overwhelming their gastrointestinal system.

Therefore, option d) Plan care to minimize handling of the newborn is the correct action to take when caring for a newborn with neonatal abstinence syndrome. It helps reduce stimulation and discomfort for the newborn.

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A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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