Nursing students describe actions while practicing physical ...

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Nursing students describe actions while practicing physical assessment of a newborn using a model. Which nursing student's statement indicates the need for further teaching?
 
  1. I auscultated the infant's heart tones for 1 minute.
  2. I palpated peripheral pulses in all the newborn's extremities.
  3. I obtained a higher blood pressure on the legs than on the arms.
  4. I obtained the infant's heart rate by observing the cardiac monitor.

Question 2

The mother of a 2-day-old infant newly diagnosed with sepsis asks why she could not detect the symptoms. What should the nurse reply to this mother?
 
  1. Your mothering skills will improve with time. You should take the newborn class.
  2. Newborns have immature immune function at birth, and illness is very hard to detect.
  3. Your baby did not get enough active acquired immunity from you during the pregnancy.
  4. The immunity your baby gets in utero does not start to function until 4 to 8 weeks of age.

[Bigfoot1984]

Answer to Question 1

4
Explanation:
1. Apical pulse rates should be obtained by auscultation for a full minute, preferably when the newborn is asleep.
2. Peripheral pulses of all extremities should also be evaluated to detect any inequalities or unusual characteristics.
3. Blood pressure in the lower extremities is usually higher than that in the upper extremities.
4. Physical assessment of the newborn's heart rate requires auscultation of the apical pulse for a full minute.

Answer to Question 2

2
Explanation:
1. This response does not address the physiology of neonatal infection and is not therapeutic because it is blaming.
2. The immune system of a newborn lacks response to pyrogens and presents a limited inflammatory response; thus, the signs and symptoms of infection are often subtle and nonspecific in the newborn.
3. The mother develops active acquired immunity, which is passed to the newborn transplacentally as passive acquired immunity. This immunity is to the illnesses and infections she has had or been immunized against.
4. The passive acquired immunity a newborn receives from its mother is effective at birth and lasts from 4 weeks to 8 months, depending on the specific antibody.