The nurse is assessing the cardiovascular status of a newborn. Which of the following findings indicates adequate systemic circulation?
A.
Capillary refill 2 seconds
B.
Capillary refill 4 seconds
C.
Pale mucous membranes in a dark-skinned baby
D.
Truncal cyanosis
ANS: A
On assessment, the systemic circulation is deemed adequate if the newborn exhibits a brisk capillary refill and stable blood pressure. Capillary refill in less than 3 seconds is considered adequate. A refill time greater than 4 seconds may be indicative of an underlying condition, such as sepsis, hypoxia, or cardiovascular or central nervous system compromise. A dark-skinned baby should have pink mucous membranes. Acrocyanosis is normal, but a cyanotic trunk is not.
You might also like to view...
A young adult woman comes to the outpatient clinic to see the nurse therapist because she states that she cannot manage her job, be a single parent, and take care of her mother who is chronically ill
During a session with both the client and her mother, the nurse finds herself feeling angry at the client's mother. Based on psychoanalytic theory, this is an example of: a. unexpressed anger b. transference c. countertransference d. sympathy
Which coping mechanism should a nurse expect to see a patient initially use to mourn the death of a spouse?
a. Denial b. Introjection c. Suppression d. Dissociation
A client in labor did not attend prenatal classes and is experiencing severe pain. In which breathing technique should the nurse instruct the client to help with relaxation and control? Select all that apply
1. Kussmaul breathing 2. Abdominal breathing 3. Slow-paced breathing 4. Pant–pant–blow breathing 5. Modified-paced breathing
During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. Which action is best for the nurse to take in response to this finding?
a. Assess the patient as thoroughly as possible. b. Explain to the patient that breast tenderness is normal at her age. c. Tell the patient that redness is not a cause for concern and is quite common. d. Inform her that redness is the precursor to normal unilateral breast enlargement.