A nurse is collecting data from a newborn who is 4 hours old.
Which of the following findings should the nurse report to the provider?
Respiratory rate 24/min.
Heart rate 150/min.
Blood pressure 82/44 mm Hg.
Temperature 37.2° C (99° F).
The Correct Answer is A
Choice A rationale
A respiratory rate of 24 breaths/min in a 4-hour-old newborn is below the normal range, which is typically between 30 and 60 breaths/min. A rate this low could indicate respiratory depression or distress, requiring immediate assessment and intervention by the healthcare provider to ensure adequate oxygenation.
Choice B rationale
A heart rate of 150 beats/min is within the normal physiological range for a newborn, which typically falls between 110 and 160 beats/min. This rate reflects the newborn's circulatory adaptation to extrauterine life and is not a cause for concern in an otherwise stable infant.
Choice C rationale
A blood pressure of 82/44 mm Hg is within the normal range for a term newborn. Normal systolic blood pressure in a newborn is generally between 60-90 mm Hg, and diastolic blood pressure is typically between 30-60 mm Hg, reflecting healthy cardiovascular function and systemic perfusion.
Choice D rationale
A temperature of 37.2° C (99° F) is within the normal range for a newborn's body temperature. The normal axillary temperature for a newborn is typically between 36.5° C and 37.5° C (97.7° F and 99.5° F), indicating appropriate thermoregulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Iron absorption is significantly enhanced by ascorbic acid (vitamin C), which is abundant in orange juice. Vitamin C converts ferric iron to ferrous iron, the more absorbable form, thereby improving bioavailability and mitigating common gastrointestinal side effects by increasing absorption efficiency in the duodenum.
Choice B rationale
Taking ferrous sulfate with breakfast, or any meal, can decrease its absorption due to interactions with certain food components like phytates in grains or calcium in dairy. Optimal absorption occurs on an empty stomach to avoid chelation or competition for absorption pathways.
Choice C rationale
Similar to breakfast, taking ferrous sulfate with a midday meal can also reduce its absorption efficiency. Food components can bind with iron, forming insoluble complexes that are not readily absorbed in the gastrointestinal tract, thereby diminishing therapeutic efficacy.
Choice D rationale
Milk contains calcium, which can significantly inhibit the absorption of iron. Calcium ions compete with iron for absorption sites in the small intestine, forming insoluble complexes that reduce iron bioavailability and diminish the effectiveness of the ferrous sulfate supplement.
Correct Answer is C
Explanation
Choice A rationale
Auscultating bowel sounds is an important assessment, but it is not the first action for a newborn with neonatal abstinence syndrome. Respiratory compromise is a life-threatening complication that requires immediate assessment to ensure adequate oxygenation and ventilation, as respiratory depression can occur due to central nervous system effects of withdrawal.
Choice B rationale
Swaddling can provide comfort and reduce hyperirritability in a newborn with neonatal abstinence syndrome. While beneficial, it is a supportive intervention. Prioritizing physiological stability, specifically respiratory status, is essential before implementing comfort measures to address potentially life-threatening complications.
Choice C rationale
Determining the newborn's respiratory rate is the first action because respiratory depression or distress is a critical and potentially life-threatening symptom of neonatal abstinence syndrome. Accurate assessment of respiratory effort, rate (normal range is 30-60 breaths/minute), and presence of retractions or nasal flaring is paramount to ensure adequate oxygenation and guide immediate interventions.
Choice D rationale
Weighing a wet diaper assesses hydration and urinary output. While important for overall assessment, it is not the immediate priority for a newborn experiencing neonatal abstinence syndrome, as respiratory stability takes precedence due to the direct threat to life that respiratory compromise can pose in these vulnerable infants.
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