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

This is the method that the nurse should use to elicit the Moro reﬂex. The Moro reﬂex, or startle reﬂex, is an involuntary motor response that infants develop shortly after birth. It is a response to a sudden loss of support or extremely sudden stimulation¹. A loud noise above the newborn can trigger the Moro reﬂex by startling the infant. The Moro reﬂex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually)².

The other options are not correct because they do not elicit the Moro reﬂex.
a) Turn the newborn's head to one side.
This does not elicit the Moro reﬂex, but rather the tonic neck reﬂex. The tonic neck reﬂex occurs when the infant turns their head to one side and assumes a "fencing" posture, with the arm and leg on the same side extended and the opposite arm and leg ﬂexed.

b) Touch the newborn's cheek with a finger.
This does not elicit the Moro reﬂex, but rather the rooting reﬂex. The rooting reﬂex occurs when the infant turns their head and opens their mouth in response to a touch on their cheek or mouth. This reﬂex helps the infant locate and latch onto a nipple for feeding³.
d) Tap the newborn's forehead with a finger.
This does not elicit the Moro reﬂex, but rather the glabellar reﬂex. The glabellar reﬂex occurs when the infant blinks in response to a tap on their forehead or bridge of their nose. This reﬂex helps protect the eyes from injury³.

A. A client who has preeclampsia and a creatinine level of 1.1 mg/dL B. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L C. A client who has diabetes mellitus and an HbA1C of 5.8% D. A client who has placenta previa and a hematocrit of 35%

Correct Answer is B

Explanation

Among the given options, the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L should be assessed first. Hyperemesis gravidarum is a condition characterized by severe and persistent vomiting during pregnancy, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L indicates hyponatremia, which is an abnormally low level of sodium in the blood.

Hyponatremia can lead to serious complications, including neurological symptoms such as confusion, seizures, and coma. Prompt assessment and intervention are necessary to correct the electrolyte imbalance and prevent further complications.

Option a) A client with preeclampsia and a creatinine level of 1.1 mg/dL should be monitored closely, as elevated creatinine levels can indicate impaired kidney function. However, in this scenario, the client with hyperemesis gravidarum and severe hyponatremia requires more immediate attention due to the potential for neurological complications.

Option c) A client with diabetes mellitus and an HbA1C of 5.8% may require further management and monitoring, but it does not present an immediate risk or urgency compared to the client with hyperemesis gravidarum and severe hyponatremia.

Option d) A client with placenta previa and a hematocrit of 35% may need close monitoring for potential bleeding, but it does not pose an immediate threat compared to the client with hyperemesis gravidarum and severe hyponatremia.

Therefore, the nurse should assess the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L as the first priority due to the risk of complications associated with severe hyponatremia.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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