The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be:
1. Temperature 97.9°F.
2. Respirations 68 breaths/minute.
3. Blood pressure 72/44.
4. Heart rate 156 beats/min.
2
Rationale 1: This is within the normal temperature range of 97.5–99°F.
Rationale 2: The normal respiratory rate is 30–60 breaths/min; 68 breaths/min could represent a less-than-ideal transition.
Rationale 3: This blood pressure is within the normal range of 90–60/50–40 mm Hg.
Rationale 4: This heart rate is within the normal range of 110–160 beats/min.
You might also like to view...
A pregnant woman is HIV-positive. She is asking about ways to decrease the risk of vertical transmission to her baby. Which option given by the nurse would confer the least risk to the baby?
A. Antiretroviral medications (zidovudine [ZDV]) B. Cesarean delivery C. Cesarean delivery plus antiretroviral medications for the newborn D. Vaginal delivery plus antiretroviral medications for the newborn
Inflammatory conditions of the musculoskeletal system usually occur from:
a. immobility c. viral infection b. pain d. repetitive use
The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions?
a. "I will give my canned soups to the food pantry." b. "I'm going to miss my evening glass of wine." c. "I will mostly use salt substitutes for flavoring." d. "I can have regular coffee only in the morning."
During the end-of-shift report, the nurse notes that the client had been very nervous and preoccupied during the evening and that no family visited
To determine the amount of anxiety that the client is experiencing, how should the nurse respond to the client? a. "Would you like for me to call a family member to come and support you?" b. "Would you like to go down the hall and talk with another client who had the same surgery?" c. "How serious do you think your illness is?" d. "You seem worried about something. Would it help to talk about it?"