The nurse is obtaining vital signs for a newborn client. Which ...

[go.lag]

The nurse is obtaining vital signs for a newborn client. Which route and sequence will the nurse use to obtain vital signs on this client?
 
  1. Rectal temperature, respirations, pulse rate.
  2. Respirations, pulse rate, blood pressure, rectal temperature.
  3. Respirations, apical pulse rate, axillary temperature.
  4. Oral temperature, respirations, pulse rate, blood pressure.

Question 2

The nurse is assessing a client's abdomen. Which sound is expected when percussion is used during the assessment?
 
  1. Loud, low-pitched.
  2. Soft, high-pitched.
  3. Drum-like.
  4. Abnormally loud.

[carojassy25]

Answer to Question 1

Correct Answer: 3

Respirations should be assessed first in the assessment of a newborn, followed by the apical pulse, and finally the infant's temperature. While the rectal temperature is the most accurate, there is risk of rectal perforation. This question addresses a healthy newborn; therefore an axillary temperature is appropriate. The temperature (any route) should be assessed last, as it may cause the infant to cry, altering the rate of respirations and pulse. A blood pressure is not a routine vital sign obtained on a healthy infant. If a blood pressure is done, a Doppler stethoscope is used in infants and children under the age of two. Oral temperatures are not used for temperature measurement in children under the age of five.

Answer to Question 2

Correct Answer: 3
Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines. Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver. Resonance is a loud, low-pitched tone of normal findings over the lungs. Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs.