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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the only option that is true and relevant to maternal cytomegalovirus infection. CMV can be transmitted from the newborn to the mother or other caregivers through contact with the saliva and urine of the newborn, which may contain high amounts of the virus. Therefore, it is important to practice good hygiene and avoid contact with these body fluids when caring for a newborn with congenital CMV.
a) This infection does not require that airborne precautions be initiated for the newborn. Airborne precautions are used to prevent the spread of infections that are transmitted by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, measles, or chickenpox. CMV is not transmitted by airborne route, and standard precautions are sufficient to prevent exposure to blood or body fluids that may contain CMV
b) Mothers will not receive prophylactic treatment with acyclovir prior to delivery. Acyclovir is an antiviral medication that is used to treat herpes simplex virus (HSV) infections, such as cold sores, genital herpes, or neonatal herpes. It has no effect on CMV infection, and it is not recommended for pregnant women or newborns with CMV.
c) Lesions are not visible on the mother's genitals. Lesions are a sign of HSV infection, not CMV infection. HSV can cause painful blisters or ulcers on the mouth or genitals, and it can be transmitted to the newborn during delivery. CMV does not cause any visible symptoms on the mother's genitals, and it can be transmitted to the newborn during pregnancy, delivery, or breastfeeding.
Correct Answer is B
Explanation
Uterine atony is a condition in which the uterus does not contract properly after delivery, leading to excessive bleeding or postpartum hemorrhage. Uterine atony can be caused by various factors, such as
prolonged or fast labor, multiple gestation, large baby, polyhydramnios, infection, or use of certain medications¹.
The nurse should monitor the client for any signs of uterine atony, such as:
- A soft or boggy uterus that does not respond to massage
- Excessive bleeding or clots from the vagina
- Low blood pressure or fast pulse
- Pale or clammy skin
- Dizziness or fainting
The nurse should also provide immediate interventions to stop the bleeding and restore uterine tone, such
as:
- Massaging the uterus firmly until it contracts
- Administering uterotonic medications as ordered to stimulate uterine contractions
- Administering intravenous fluids and blood products as needed to replace blood loss
- Notifying the provider and preparing for possible surgical procedures if bleeding persists
Uterotonic medications are drugs that cause the uterus to contract and reduce bleeding. They are used to prevent or treat postpartum hemorrhage due to uterine atony. The most common uterotonic medications are:
- Oxytocin: a hormone that is naturally produced by the body during labor and breastfeeding. It is the first- line drug for uterine atony and is given intravenously or intramuscularly. It causes strong and sustained contractions of the uterus and also reduces blood pressure and pain. It has few side effects, but it can cause water retention, nausea, vomiting, or headache in high doses²³.
- Methylergonovine: a synthetic derivative of ergot, a fungus that grows on rye. It is a second-line drug for uterine atony and is given intramuscularly or orally. It causes prolonged contractions of the uterus and also constricts blood vessels in other parts of the body. It can cause side effects such as hypertension, headache, nausea, vomiting, chest pain, or allergic reactions. It is contraindicated in clients with hypertension, preeclampsia, cardiac disease, or liver disease²³.
- Carboprost: a synthetic form of prostaglandin F2 alpha, a hormone that regulates inflammation and blood clotting. It is a third-line drug for uterine atony and is given intramuscularly. It causes intense contractions of the uterus and also relaxes smooth muscles in other parts of the body. It can cause side effects such as fever, diarrhea, nausea, vomiting, bronchospasm, or allergic reactions. It is contraindicated in clients with asthma, liver disease, or kidney disease²³.
- Misoprostol: a synthetic form of prostaglandin E1, a hormone that protects the stomach lining from ulcers. It is an alternative drug for uterine atony and is given orally, rectally, sublingually, or vaginally. It causes mild to moderate contractions of the uterus and also dilates blood vessels in other parts of the body. It can cause side effects such as fever, chills, shivering, nausea, vomiting, diarrhea, or abdominal pain. It is contraindicated in clients with allergy to prostaglandins²³.
Therefore, the nurse should anticipate the use of methylergonovine for a client who has uterine atony that does not respond to oxytocin administration. The nurse should also monitor the client's blood pressure and vital signs closely and report any adverse reactions to the provider.
The other options are not medications that the nurse should anticipate the use of for uterine atony:
- a) Terbutaline is a medication that belongs to a class of drugs called beta-adrenergic agonists. It is used to relax the smooth muscles of the bronchi and uterus. It is used to treat asthma and preterm labor by preventing or stopping contractions. It is not indicated for uterine atony and can cause side effects such as tachycardia, palpitations, tremors, anxiety or hypotension²⁴.
- c) Hydralazine is a medication that belongs to a class of drugs called vasodilators. It is used to lower blood pressure by relaxing the smooth muscles of the arteries. It is used to treat hypertension and preeclampsia by reducing vascular resistance and improving blood flow. It is not indicated
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