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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Three uterine contractions within a 20-min period require intervention by the nurse during a nonstress test at 35 weeks of gestation. The nonstress test is used to assess fetal well-being by monitoring the fetal heart rate (FHR) response to fetal movement. The test is considered reactive if there are two or more accelerations of the FHR within a 20-min period, each lasting at least 15 seconds and peaking at least 15 beats above the baseline. In this scenario, the finding that requires intervention by the nurse is three uterine contractions within a 20-min period. This is because frequent or prolonged contractions can indicate preterm labor, which requires immediate intervention
to prevent premature delivery. The nurse should assess the client for signs and symptoms of preterm labor, such as pelvic pressure, low back pain, vaginal bleeding or discharge, and abdominal cramping. The nurse should also notify the provider and prepare the client for further evaluation and possible interventions, such as tocolytic therapy to stop the contractions.
Correct Answer is B
Explanation
A. This option is incorrect because the development of breast tissue in newborns is not directly related to the mother’s hormone levels during pregnancy. Newborns typically have breast buds regardless of maternal hormone variations.
B. A flat areola with no breast bud is a characteristic finding in preterm newborns. Breast tissue development is one of the physical markers used to assess gestational age, and the lack of a breast bud is an indicator of immaturity, suggesting a preterm gestational age.
C. Ambiguous secondary sex characteristics are not related to the presence or absence of breast buds in newborns. This option focuses on sexual development rather than gestational markers.
D. A flat areola with no breast bud is a normal finding in preterm infants and does not indicate a congenital anomaly. This condition is expected in preterm newborns based on their developmental stage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.