A nurse is assessing a newborn 2 hr following birth. Which of the following findings should the nurse expect?
Heart rate 190/min
Irregular respirations
Central cyanosis
Temperature of 38.2° C (100.8° F)
The Correct Answer is B
A. Heart rate 190/min: A normal newborn heart rate ranges from 120 to 160 beats per minute. A heart rate of 190/min is tachycardic and is above the expected range for a healthy newborn.
B. Irregular respirations: Newborns often exhibit irregular respirations with periods of rapid breathing followed by pauses. This pattern is expected in the first few hours after birth and usually does not indicate distress if oxygen saturation is normal.
C. Central cyanosis: Central cyanosis, including blue lips or tongue, is abnormal and may indicate hypoxemia or congenital heart or respiratory issues. Normal newborns may show brief acrocyanosis of hands and feet but not central cyanosis.
D. Temperature of 38.2° C (100.8° F): A normal newborn temperature ranges from 36.5° C to 37.5° C (97.7° F to 99.5° F). A temperature of 38.2° C is elevated and may indicate infection or overheating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "This medication may cause me to experience a metallic taste in my mouth.": Lorazepam is a benzodiazepine and does not commonly cause a metallic taste. This statement reflects a misunderstanding of common adverse effects associated with the medication.
B. "This medication can cause my potassium level to decrease.": Lorazepam does not affect electrolyte levels such as potassium. Monitoring potassium is not typically necessary with this medication, so this statement is inaccurate.
C. "This medication can cause drowsiness.": Drowsiness is a common side effect of lorazepam due to its sedative properties. Understanding this effect helps the client anticipate and manage daytime sleepiness and avoid activities requiring alertness, demonstrating correct comprehension of teaching.
D. "This medication may cause me to lose weight.": Lorazepam is not associated with weight loss. Clients should be informed about the expected side effects, and weight changes are not typical with this medication, making this statement incorrect.
Correct Answer is D
Explanation
A. Severe abdominal pain: Severe abdominal pain is more commonly associated with placental abruption, not placenta previa. In placenta previa, the placenta covers the cervical opening, which typically causes painless bleeding rather than significant abdominal discomfort.
B. Delayed menses: Delayed menses is not related to placenta previa. This condition occurs during pregnancy, after menses have already ceased, and does not influence menstrual timing.
C. Nausea: Nausea is a common symptom in early pregnancy due to hormonal changes but is not a characteristic finding of placenta previa. It does not help in diagnosing or identifying this placental complication.
D. Spotting: Spotting or painless vaginal bleeding, especially in the second or third trimester, is a hallmark sign of placenta previa. The bleeding occurs because the placenta partially or completely covers the cervical os, and it often requires careful monitoring and management to prevent maternal and fetal complications.
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