The assessment of a newborn at 1 hour of age reveals the following: temperature 36.0° C (96.7° F), heart rate 158 beats/minute, respiratory rate 55 breaths/minute, color pink with acrocyanosis
Based on these clinical findings, the nurse should conclude that:
a. The infant is in respiratory distress.
b. Measures to warm the infant should be taken.
c. The infant is showing signs of cold stress.
d. No nursing interventions are necessary.
ANS: B
The temperature is low, and measures should be instituted to warm the infant to prevent cold stress. The heart and respiratory rates are within normal ranges.
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A. Aqueductal stenosis B. Chiari I and II malformations C. Dandy-Walker malformation D. Folic acid deficiency
The clinical nurse specialist meets with the interdisciplinary staff members planning care for a client
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A female patient who is recovering from a stroke has begun eating a minced and pureed diet after passing the speech pathologist's swallowing assessment
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Nursing interventions are selected based on an understanding of scientific principle, psychosocial responses, or developmental theories
Indicate whether the statement is true or false