Author Question: The nurse is about to take vital signs on a newborn patient in the nursery. She should: a. assess ... (Read 37 times)

ap345 · **on:** Jun 25, 2018

The nurse is about to take vital signs on a newborn patient in the nursery. She should:

a. assess respiratory rate after taking a rectal temperature.
b. observe the child's chest while the child is sleeping.
c. call the physician if the rate is over 40.
d. expect that the child will have short periods of apnea.

Question 2

The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices that the skin remains suspended for a longer than normal period. What could this indicate?

a. Stage I pressure ulcer
b. Increased blood flow to the area
c. Localized vasodilation
d. Dehydration

lin77x · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

D
An irregular respiratory rate and short apneic spells are normal for newborns. Assess respiratory rate before other vital signs or assessments are taken. Children up to age 7 breathe abdominally, so respirations are observed by abdominal movement. Average respiratory rate (breaths per minute) for newborns is 30 to 60; for infants (6 months to 1 year), 30 to 50; for toddlers (2 years), 25 to 32; and for children from 3 to 12 years, 20 to 30.

Answer to Question 2

D
With reduced turgor, the skin remains suspended or tented for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. A stage I pressure ulcer may cause warmth and erythema (redness) of an area. Skin temperature reflects an increase or decrease in blood flow. Normal reactive hyperemia (redness) is a visible effect of localized vasodilation, the body's normal response to lack of blood flow to underlying tissue.