Which newborn assessment finding of 24-hour-old infant should the practical nurse (PN) report to the charge nurse immediately?
Weight loss of 4 ounces since birth.
Respiratory rate of 55 breaths/minute.
Axillary temperature of 97.6° F (36.4° C).
Heart rate of 100 beats/minute.
The Correct Answer is D
The newborn assessment finding that the practical nurse (PN) should report to the charge nurse immediately for a 24-hour-old infant is a heart rate of 100 beats/minute. The normal heart rate for a newborn is between 120-160 beats/minute. A heart rate of 100 beats/minute is below the normal range and may indicate a problem such as hypothermia or an infection. The PN should report this finding to the charge nurse immediately so that appropriate action can be taken to address the issue. The other assessment findings listed may also be important to monitor, but a heart rate of 100 beats/minute is the most urgent and requires immediate attention.
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Related Questions
Correct Answer is D
Explanation
The PN should acknowledge the client's emotional state and allow him to express his feelings while also obtaining more information about the situation. By asking the client to share what he was told by the healthcare provider, the PN can gain a better understanding of the client's knowledge of the disease and provide appropriate education and support. Options A, B, and C are incorrect because they do not address the client's emotional state or provide helpful information to the PN in this situation.
Correct Answer is A
Explanation
Baclofen is a muscle relaxant that can help relieve muscle spasms and manage conditions such as cerebral palsy¹. An assessment finding that indicates the drug is effective for a child with cerebral palsy would be decreased muscular spasticity. This means that the child's muscles are less stiff and rigid, which can improve their mobility and overall quality of life.
The other choices are incorrect because they are not directly related to the therapeutic effects of baclofen. Baclofen is a muscle relaxant that is used to relieve muscle spasms and stiffness. While it may have other effects on the body, its primary therapeutic effect is to decrease muscular spasticity.
- Increased appetite is not a known effect of baclofen.
- Sufficient urinary output is important for overall health, but it is not directly related to the effectiveness of baclofen.
- Fewer temper outbursts may be an indirect result of decreased muscular spasticity and improved mobility, but it is not a direct effect of baclofen.
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