Author Question: The nurse has received a shift change report on infants born within the last four hours. Which ... (Read 50 times)

APUS57 · **on:** Jun 28, 2018

The nurse has received a shift change report on infants born within the last four hours. Which newborn should the nurse see first?

1. 37-week male, respiratory rate 45
2. 8 pound, 1 ounce female, pulse 150
3. Term male, grunting respirations
4. 39-week female, temperature 97.0F

Question 2

Which of the following actions must a nurse perform before weighing the newborn during the admission procedure?

1. Clean the scale
2. Take the infant's temperature
3. Cover the scale
4. Zero the scale
5. Wrap the infant tightly in a blanket to prevent heat loss

lorealeza · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

Correct Answer: 3
Rationale 1: A normal respiratory rate is 3060. This infant has no unexpected findings.
Rationale 2: A normal pulse is 110160. This infant has no unexpected findings.
Rationale 3: Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly intervention immediately.
Rationale 4: A normal temperature is 96.8F-97.7F. This infant has no unexpected findings.

Answer to Question 2

Correct Answer: 1,2,3,4
Rationale 1: This action should be performed to prevent cross infection.
Rationale 2: This action should be performed to monitor heat loss.
Rationale 3: This action should be performed to prevent cross infection.
Rationale 4: This action should be performed to ensure an accurate measurement.
Rationale 5: The nurse should remove all clothing and blankets to ensure an accurate measurement. To prevent heat loss, the infant should instead be placed under a radiant warmer.