A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?
Respiratory rate 55/min
Heart rate 72/min
Temperature 36.5° C (97.7° F)
Blood pressure 80/50 mm Hg
The Correct Answer is B
A. A respiratory rate of 55 breaths per minute is within the normal range for a full-term newborn, which is generally between 30 and 60 breaths per minute.
B. A heart rate of 72 beats per minute is significantly lower than the normal range for a newborn. Normal heart rates for newborns typically range from 120 to 160 beats per minute. A heart rate this low could indicate bradycardia, which requires immediate assessment and intervention.
C. A temperature 36.5° C (97.7° F) is slightly below the normal range for newborns, which is typically between 36.6°C to 37.2°C (97.9°F to 99.0°F). However, it may not be immediately concerning unless it is part of a pattern or accompanied by other symptoms.
D. A blood pressure reading of 80/50 mm Hg is within the expected range for a full-term newborn, where typical values are approximately 60-80 mm Hg for systolic and 40-50 mm Hg for diastolic.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Cranial bone overlap (molding) is common after vaginal delivery due to compression during birth. It typically resolves within a few days and does not require urgent intervention.
B.These are called milia, which are harmless and expected in newborns. They resolve spontaneously without treatment.
C.This is known as acrocyanosis, a normal finding in newborns during the first 24–48 hours of life due to immature circulation. It is not a cause for concern unless central cyanosis is present (e.g., lips or mucous membranes are blue).
D.Abnormal positioning of the ears (e.g., low-set or forward and lateral) can be a sign of congenital anomalies, particularly renal abnormalities or chromosomal syndromes such as Trisomy 21 (Down syndrome) or Trisomy 18. Because these may indicate serious underlying systemic conditions, the nurse must report this finding promptly to initiate further evaluation and possibly diagnostic testing (e.g., renal ultrasound or genetic consultation).
Correct Answer is B
Explanation
The client who understands the teaching on listeriosis and dietary modifications during pregnancy states that they can eat grilled chicken on a bun at lunchtime. Listeriosis is a bacterial infection that can cause miscarriage, stillbirth, or severe illness in newborns. Clients should avoid certain high-risk foods during pregnancy, such as soft cheeses, deli meats, seafood salads, and hot dogs. Grilled chicken on a bun is a safe option for the client to consume.
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