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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Asking if the client has considered harming her newborn is a priority to assess for potential postpartum depression or psychosis, which require immediate intervention. .

A. Axillary temperature 36.1°C (97°F). B. Respiratory rate 78/min. C. Nasal flaring present. D. Fontanel level and soft with large ecchymotic tinge.

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

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

Choice D rationale

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn.The client reports feeling "down" and sad, having no energy, and wanting to cry.Which of the following is a priority action by the nurse?

Correct Answer is A

Explanation

Correct Answer is ["B","C","D"]

Explanation

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