A nurse observes an infant in a crib lying still, without facial ...

[elizabeth18]

A nurse observes an infant in a crib lying still, without facial movements, except for occasional sucking movements. At this time, the nurse will avoid:
 
  1. Assessing heart and respiratory rate.
 
  2. Skin assessment.
 
  3. Repositioning the head of the infant.
 
  4. Attempts to feed the infant.

Question 2

During the newborn assessment, a systolic blood pressure that is higher in the legs than in the arms is suggestive of which of the following findings?
 
  1. Cardiac arrhythmia
   2. Coarctation of the aorta
   3. Chromosome abnormality
   4. A normal finding for an infant

[stano32]

Answer to Question 1

4

Rationale:

1. There is no contraindication to assessing the heart and respiratory rate.
2. There is no contraindication to assessing the infant's skin.
3. Repositioning the head of the infant is acceptable to do while the infant is in a deep sleep.
4. This infant is in a quiet, deep sleep. Attempts to feed the infant should not be made until the infant is in a lighter sleeping pattern, since the infant will be unresponsive to attempts at arousal, and might be at risk for aspiration.

Answer to Question 2

4
Rationale:
1. A cardiac arrhythmia would decrease cardiac output, and would result in lower pressure in all extremities.
2. Coarctation of the aorta would result in lower pressures in the legs than in the arms.
3. A chromosomal abnormality would not be directly associated with blood pressure differences.
4. This is a normal finding in the child, because blood takes the path of least resistance, making pressures lower in the arms than legs.