The nurse is performing a physical assessment on a term newborn delivered two hours ago.
Which assessment findings require follow-up?
The nurse is performing a physical assessment on a term newborn delivered two hours ago.
Which assessment findings require follow-up?
A. Axillary temperature 36.6°C (97.9°F)
[11%]
B. Apical pulse 121
[14%]
C. 2+ brachial pulses bilaterally
[7%]
D. Respirations 28
[68%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Newborn
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Knowledge/Comprehension
Explanation
Choice D is correct. The expected respiratory rate for a term newborn is 35–55 breaths per minute. A rate of 28 is bradypnea, which could indicate central nervous system depression, hypothermia, or sepsis, especially in a newborn only two hours old.
Choice A is incorrect. This temperature is within normal limits. The normal temperature for a newborn is 36.5° to 37.5°C (97.7° to 99.5°F) axillary.
Choice B is incorrect. This pulse is within normal limits. The normal apical pulse for a newborn is 120 to 160 bpm (100 sleeping, 180 crying).
Choice C is incorrect. Pulses should be 2+. Pulses should be equal bilaterally, and the brachial and femoral pulse rates should be the same.
Related Videos
2 Key Topics
Pediatric Vital Signs
31.1 Immediate Newborn Evaluation
Additional Info
