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The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
- A. 30 to 60
- B. 22 to 28
- C. 16 to 20
- D. 10 to 15
Correct Answer: A
Rationale: Newborn respiratory rate is 30-60 breaths/min; rapid breathing within this (A) is normal if pink, warm, dry. Lower ranges (B, C, D) apply to older ages. Choice A is correct, per neonatal norms, guiding care planning.
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The nurse needs to increase heat conservation in a newborn. Which action will the nurse take?
- A. Apply just a diaper.
- B. Double the clothing.
- C. Place a cap on their heads.
- D. Increase room temperature to 90 degrees.
Correct Answer: C
Rationale: Newborns lose heat rapidly, especially from the head, due to a large surface area and limited thermoregulation. Placing a cap (C) conserves heat by covering this key area, a standard neonatal practice. A diaper alone (A) offers minimal coverage, increasing heat loss. Doubling clothing (B) helps but is less effective than a cap for head protection. Raising the room to 90?°F (D) risks overheating. Choice C is correct, supported by pediatric guidelines (e.g., AAP) emphasizing head coverage to maintain newborn temperature stability.
When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action?
- A. It is not affected by skin moisture.
- B. It has no risk of injury to patient or nurse.
- C. It reflects rapid changes in radiant temperature.
- D. It is accurate even when the forehead is covered with hair
Correct Answer: B
Rationale: Temporal artery thermometers are non-invasive, posing no injury risk (B), ideal for newborns and children. Moisture (A) can affect accuracy. Radiant changes (C) are less relevant. Hair (D) interferes. Choice B is correct, per pediatric safety standards.
The nurse is caring for an older-adult patient and notes that the temperature is 96.8?°F (36?°C). How will the nurse interpret this?
- A. This is normal for an older adult.
- B. This is too high for an older adult.
- C. This is indicative of infection.
- D. This requires immediate intervention.
Correct Answer: A
Rationale: Older adults often have lower baseline temperatures (e.g., 96.8?°F) due to slower metabolism; (A) is normal. Too high (B) or infection (C) doesn't fit without symptoms. Intervention (D) is unnecessary. Choice A is correct, per geriatric nursing norms.
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?
- A. Temperatures vary depending on the route used.
- B. Temperatures are readings of core measurements.
- C. Rectal temperatures are cooler than when taken orally.
- D. Axillary temperatures are higher than oral temperatures.
Correct Answer: A
Rationale: Temperature varies by route (A) e.g., rectal is 1?°F higher, axillary 1?°F lower than oral requiring documentation for accuracy. Not all are core (B). Rectal is warmer (C incorrect). Axillary is lower (D incorrect). Choice A is correct, per nursing documentation standards.
The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?
- A. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist.
- B. Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist.
- C. Place the thumb over the groove along the little finger side of the patient's wrist.
- D. Place the thumb over the groove along the thumb side of the patient's wrist.
Correct Answer: A
Rationale: Radial pulse is palpated with the first two fingers along the thumb side groove (A), ensuring accuracy without thumb pressure interference. Little finger side (B, C) is incorrect anatomically. Thumb use (C, D) distorts readings. Choice A is correct, per nursing technique standards, for reliable radial pulse measurement.