A nurse is receiving a report on four newborns born in the past 12 hr. Which of the following newborns should the nurse assess first?
A newborn who has a respiratory rate of 34/min.
A newborn who has acrocyanosis.
A newborn who has caput succedaneum.
A newborn who has an axillary temperature of 36°C (96.8°F).
The Correct Answer is D
Choice A rationale
A respiratory rate of 34/min is within the normal range for a newborn, which is typically between 30 to 60 breaths per minute. This does not indicate immediate distress.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves within the first few days of life. It is not a sign of critical illness.
Choice C rationale
Caput succedaneum, a swelling of the soft tissues of the newborn's scalp, is a common and benign condition that resolves on its own within a few days. It does not require immediate medical attention.
Choice D rationale
An axillary temperature of 36°C (96.8°F) is considered low and may indicate hypothermia in a newborn. Hypothermia can lead to serious complications, so this newborn requires immediate assessment and intervention to stabilize their body temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
The client is most likely experiencing an ectopic pregnancy. Here's why:
- Symptoms: The client presents with intermittent vaginal bleeding and dull left lower quadrant abdominal pain, which are common symptoms of an ectopic pregnancy.
- Physical Examination: Tenderness upon palpation in the left lower quadrant and an enlarged uterus consistent with 8 weeks of gestation are also indicative of an ectopic pregnancy.
Actions to Take
- Perform ultrasound: To confirm the diagnosis and locate the ectopic pregnancy.
- Administer IV fluids: To stabilize the client and prepare for potential surgical intervention.
Parameters to Monitor
- Vaginal bleeding: To assess the severity and progression of the bleeding.
- Blood pressure: To monitor for signs of internal bleeding or hemodynamic instability.
Correct Answer is D
Explanation
Choice A rationale
Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.
Choice B rationale
A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.
Choice C rationale
Late decelerations are concerning and not expected as they may indicate fetal distress.
Choice D rationale
Contractions lasting about 75 seconds are expected during the active phase of labor.
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