The nurse is assessing a full-term African American newborn that is 18 hours old. The nurse would document which of the following as a normal finding?
1. Lethargy
2. Heart rate 115–120
3. Bulging of the precordium
4. Pale conjunctiva
2
Rationale 1: The infant should be easily aroused and alert.
Rationale 2: The heart rate of a newborn initially may be as high as 175–180 beats per minute but should decrease over the next 6 to 8 hours to about 115–120 beats per minute.
Rationale 3: Precordial bulging should always be evaluated and is never considered a normal finding.
Rationale 4: The skin should demonstrate perfusion with pink quality in the nail beds, mucous membranes, and conjunctiva regardless of the baby's race.
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1. normal. 2. prehypertension. 3. stage I hypertension. 4. stage II hypertension.
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A) Depression. B) Avoidant personality disorder. C) Delirium. D) Bipolar disorder.