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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: B. Limit play with the stuffed toy when out of the tent.
Rationale:
A) Spray the toy with disinfectant before placing it in the tent: Disinfecting the toy may not be necessary unless the toy is visibly soiled. Moreover, the use of disinfectants around the child may pose a risk of respiratory irritation, making this option inappropriate.
B) Limit play with the stuffed toy when out of the tent: This action is appropriate as it helps minimize the risk of cross-contamination and reduces exposure to potential allergens or irritants that may worsen the child's condition. Keeping the toy limited to the tent allows for a safer environment for the child.
C) Allow the child to have the stuffed toy in the tent: While having a favorite toy can provide comfort, it’s crucial to ensure that the toy does not harbor germs that could exacerbate the child's illness. In a mist tent, moisture can also promote mold growth on soft toys, so extra caution is necessary.
D) Ask the mother to wash the toy daily at home: While washing the toy is a good practice, this option does not directly address the immediate care in the hospital setting. Daily washing might not be feasible for the mother during the hospital stay, and it does not focus on minimizing exposure during the child’s hospitalization.
Correct Answer is B
Explanation
The PN should report the injury details to the charge nurse. This is important because the charge nurse needs to be aware of any changes in the patient's condition and can help determine the appropriate course of action. The other options are not the most appropriate actions for the PN to take in this situation.
Obtaining a heel stick glucose (A) may be necessary if hypoglycemia is suspected, but it is not the most immediate concern.
Initiating strict intake and output measurements (C) may be necessary for monitoring fluid balance, but it is not the most immediate concern.
Swaddling the infant in a blanket (D) may provide comfort, but it does not address the underlying issue of the head injury and seizure episode.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today