A nurse is analyzing assessment findings on four different newborns. Which assessment finding on a newborn might suggest a congenital heart defect?
1. Apical heart rate of 140 beats per minute
2. Respiratory rate of 40
3. Acrocyanosis
4. Cyanosis of the buccal membranes
4
Rationale:
1. Apical heart rate of 140 is a normal assessment finding for newborns.
2. Respiratory rate of 40 is a normal assessment finding for newborns.
3. Acrocyanosis (cyanosis of the extremities) is a normal assessment finding for newborns.
4. Cyanosis of the buccal membranes is not a normal finding in a newborn, and could indicate a congenital heart defect.
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ANS:
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