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 C
Explanation
Choice A rationale
While burping is important after feeding to prevent discomfort and regurgitation, it does not directly indicate overall health or hydration status.
Choice B rationale
Frequent loose yellow stools are typical in breastfed infants and indicate proper digestion and nutrition, but do not address overall hydration status directly.
Choice C rationale
Steady weight gain indicates good nutrition and overall health in the infant, reflecting adequate feeding and hydration.
Choice D rationale
Sleeping through the night is not an expectation for newborns, as they typically need frequent feeding due to small stomach capacity and rapid growth needs.
Correct Answer is C
Explanation
Choice A rationale
Focusing primarily on her own needs is characteristic of the taking-in phase, where the mother is more self-focused and recovering from the birth process.
Choice B rationale
Being very excited and talkative about the birth experience is also a trait of the taking-in phase, not the taking-hold phase.
Choice C rationale
Interest in learning about infant care indicates the taking-hold phase, where the mother becomes more focused on the baby's needs and her new role as a caregiver.
Choice D rationale
Relying on nursing staff for assistance is common in the taking-in phase, where the mother depends more on others for care.
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