A nurse is caring for a newborn immediately following birth.
The nurse is assessing the newborn 24 hr later.
How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.
Findings 24 hr later:
Color: Consistent with genetic background.
Axillary temperature 36.3° C (97.4°F). Reflex irritability: cry.
Muscle tone: flaccid.
Respiration effort: good cry.
Heart rate 140/min.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}
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Color: Consistent with genetic background
- Interpretation: B) Sign of potential improvement
- Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.
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Axillary Temperature: 36.3°C (97.4°F)
- Interpretation: B) Sign of potential improvement
- Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.
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Reflex Irritability: Cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.
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Muscle Tone: Flaccid
- Interpretation: C) Sign of potential worsening condition
- Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.
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Respiration Effort: Good cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.
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Heart Rate: 140/min
- Interpretation: B) Sign of potential improvement
- Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.
Correct Answer is B
Explanation
Choice A rationale:
Removing the diaphragm 2 to 4 hours after intercourse is incorrect because the diaphragm should be left in place for at least 6 hours after intercourse to prevent pregnancy.
Choice B rationale:
Inserting the diaphragm up to 6 hours before intercourse is correct. This allows time for the spermicide to become effective.
Choice C rationale:
Washing the diaphragm with detergent soap between uses is incorrect. Detergent soap can degrade the material of the diaphragm.
Choice D rationale:
Applying a vaginal lubricant to the diaphragm prior to insertion is incorrect. Lubricants can interfere with the effectiveness of the spermicide.
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