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 D

Explanation

In a newborn, bluish discoloration of the hands and feet may indicate a condition called peripheral cyanosis, which suggests poor oxygenation. It is important to report this finding to the healthcare provider promptly, as it may indicate a respiratory or circulatory problem that requires immediate attention.

Option a) Overlapping of the cranial bones is a common finding in newborns due to the molding of the head during delivery. This is not a priority finding to report unless there are other signs of concern, such as abnormal head shape or signs of trauma.

Option b) Small, distended white sebaceous glands on the face are called milia and are a normal finding in newborns. They are not a priority finding to report and typically resolve on their own within a few weeks.

Option c) Forward and lateral positioning of the ears is a normal finding in a newborn and is not a priority to report. The ears may appear folded or positioned diﬀerently due to the pressure and positioning in the womb.

Correct Answer is ["3"]

Explanation

Use the following formula to calculate the amount of gentamicin to administer:

Volume (mL) = Dose (mg) / Concentration (mg/mL)

First, I need to convert the client's weight from pounds to kilograms. One pound is equal to 0.4536 kilograms. Therefore, 132 lb is equal to 132 x 0.4536 = 59.8752 kg.

Next, I need to multiply the client's weight by the prescribed dose of gentamicin per kilogram. The prescribed dose is 2 mg/kg, so the total dose is 2 x 59.8752 = 119.7504 mg.

Finally, I need to divide the total dose by the concentration of gentamicin in the injection. The concentration is 40 mg/mL, so the volume is 119.7504 / 40 = 2.99376 mL.

To round the answer to the nearest whole number, I need to look at the first decimal place. If it is 5 or more, I round up; if it is less than 5, I round down. In this case, the first decimal place is 9, which is more than 5, so I round up. Therefore, the final answer is 3 mL.

The nurse should administer 3 mL of gentamicin injection to the client.

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

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who is 4 hr. old. Which of the following findings should the nurse identify as the priority to report to the provider?

Correct Answer is D

Explanation

Correct Answer is ["3"]

Explanation

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