The nurse assesses the following in a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be:

1. Skin temperature 97.6°F
2. Respirations 68/min
3. Blood pressure 72/44
4. Heart rate 156 beats/min


Correct Answer: 2
Rationale 1: This is within the normal temperature range of 96.8–97.7°F.
Rationale 2: Normal respiratory rate is 40–60 breaths/min. 68 could represent a less-than-expected transition.
Rationale 3: This blood pressure is within the normal range of 90–60/50–40 mmHg.
Rationale 4: This heart rate is within the normal range of 120–160 beats/min.

Nursing

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