A nurse is caring for a newborn 8 hours old.
Axillary temperature: 37.1°C (96.8°F). Heart rate: 132/min.
Respiratory rate: 52/min.
At 36 hours of age: Axillary temperature: 36.1°C (97°F). Heart rate: 160/min.
Respiratory rate: 78/min.
Which of the following assessment findings require follow-up by the nurse?
lowing assessment findings require follow-up by the nurse?
Axillary temperature 36.1°C (97°F).
Respiratory rate 78/min.
Nasal flaring present.
Fontanel level and soft with large ecchymotic tinge.
Correct Answer : B,C,D
Choice A rationale
Axillary temperature of 36.1°C (97°F) is within the normal range for a newborn. It does not necessarily indicate a problem that requires follow-up. Temperature regulation in newborns can vary, and this value is not concerning.
Choice B rationale
Respiratory rate of 78/min is higher than the normal range for newborns (30-60 breaths per minute). This could indicate respiratory distress and requires follow-up to determine the underlying cause.
Choice C rationale
Nasal flaring is a sign of respiratory distress in newborns. It indicates that the baby is having difficulty breathing and requires immediate follow-up to assess the severity and provide appropriate interventions.
Choice D rationale
A fontanel that is level and soft with a large ecchymotic tinge could indicate bruising or trauma. This finding is unusual and requires follow-up to determine the cause and ensure there is no underlying issue that needs to be addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Positive Moro and stepping reflexes are normal findings in newborns and are not specifically associated with dehydration or SGA.
Choice B rationale
Scant vernix is common in full-term babies and not indicative of SGA or dehydration.
Choice C rationale
Blood glucose levels provided are within normal range for newborns and do not indicate dehydration.
Choice D rationale
Tenting of the skin and dry lips are signs of dehydration, which can be associated with SGA newborns due to insufficient fluid intake. .
Correct Answer is B
Explanation
Choice A rationale
Applying hot compresses to the breasts prior to feeding is not recommended for painful nipples due to breastfeeding. It may exacerbate pain and discomfort.
Choice B rationale
Teaching latching and releasing of suction techniques helps ensure that the baby latches correctly and releases properly from the breast, which can prevent and alleviate nipple pain and trauma.
Choice C rationale
Rubbing colostrum on the nipples after a feeding session is beneficial as colostrum has healing properties, but it does not address the immediate technique-related cause of painful nipples.
Choice D rationale
Air-drying nipples for 10 minutes at the end of the feeding session can be helpful for healing, but proper latching techniques are more effective in preventing nipple pain.
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