Author Question: The nurse is assessing a full-term African American newborn who is 18 hours old. Which assessment ... (Read 122 times)

swpotter12 · **on:** Jun 25, 2018

The nurse is assessing a full-term African American newborn who is 18 hours old. Which assessment finding would the nurse document as normal for this newborn?

1. Lethargy.
2. Heart rate 115-120.
3. Bulging of the precordium.
4. Pale conjunctiva.

Question 2

The nurse is preparing to assess the female client's cardiovascular system during a routine health assessment visit. Which items should the nurse have available in the room in order to complete the examination?

Select all that apply.
1. Ruler (metric).
2. Stethoscope.
3. Lamp.
4. Client gown and a drape.
5. An ultrasound machine.

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

Answer to Question 1

Correct Answer: 2
The infant should be easily aroused and alert. The heart rate of a newborn initially may be as high as 175-180 beats per minute but should decrease over the next 6 to 8 hours to about 115-120 beats per minute. Precordial bulging should always be evaluated and is never considered a normal finding. The skin should demonstrate perfusion with pink quality in the nail beds, mucous membranes, and conjunctiva regardless of the baby's race.

Answer to Question 2

Correct Answer: 1, 2, 3, 4
The nurse will require a metric ruler to determine distention of blood vessels, a stethoscope to auscultate the client's heart and arteries, and a lamp or adequate lighting in the room for the inspection process of the assessment. Female clients should be provided with a gown and a drape for this examination in order to maintain privacy and avoid overexposure. A Doppler device, not an ultrasound machine can be used to determine the presence of a pulse if the nurse is unable to adequately palpate the pulse.