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 ["A","B","D"]
Explanation
Choice A rationale
A large ecchymotic caput succedaneum, which is swelling of the scalp due to birth trauma, usually resolves within a few days. However, its large size and presence of bruising should be monitored for potential complications such as jaundice.
Choice B rationale
Yellow discoloration of the sclera and oral mucosa indicates jaundice, which can be due to hyperbilirubinemia. This condition requires follow-up and possible treatment to prevent severe complications.
Choice C rationale
A level and soft fontanel in a newborn is a normal finding. It does not require follow-up as it indicates that intracranial pressure is normal.
Choice D rationale
A respiratory rate of 78/min in a newborn is significantly higher than the normal range (30-60/min). This finding requires follow-up to assess for respiratory distress or other underlying conditions.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Abnormal respiratory assessment findings, such as increased respiratory rate or difficulty breathing, could indicate respiratory distress or infection and should be reported to the provider for immediate evaluation.
Choice B rationale
Hemoglobin level is a critical indicator of blood loss and overall oxygen-carrying capacity. A low level postpartum could suggest significant blood loss or anemia and requires reporting.
Choice C rationale
A heart rate of 106/min is higher than normal and could indicate underlying issues such as pain, anxiety, or hemorrhage. It should be reported to the provider for further assessment.
Choice D rationale
A constant trickle of blood at the vagina could indicate ongoing bleeding from a laceration or retained placental fragments, requiring immediate attention and intervention by the provider. .
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