Nokea
The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology?
- A. Small glomeruli
- B. Minimal renal blood flow
- C. Inactive gastrointestinal (GI) tract
- D. Excessive fluid loss from the sweat glands
- E. Immature renal tubules that do not concentrate urine
Correct Answer: A,B,E
Rationale: Newborns are prone to dehydration due to small glomeruli, minimal renal blood flow, and immature renal tubules that do not concentrate urine effectively.
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The nurse is measuring the vital signs of a calm, full-term newborn. Which finding is abnormal?
- A. An axillary temperature of 36.6?°C (98?°F)
- B. An apical pulse rate of 178 beats/minute
- C. Respirations of 35 breaths/minute
- D. Blood pressure of 80/50 mm Hg
Correct Answer: B
Rationale: The normal range for a newborn's pulse rate is 110 to 160 beats/minute. A pulse rate of 178 beats/minute is abnormal and should be reported.
The nurse is assessing Apgar score on a newborn. What will be evaluated?
- A. Reflexes
- B. Color
- C. Heart rate
- D. Respiration
- E. Weight
Correct Answer: A,B,C,D
Rationale: The Apgar score evaluates heart rate, respiration, muscle tone, reflexes, and color at 1 and 5 minutes after birth.
A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later?
- A. 2900
- B. 3100
- C. 3300
- D. 3800
Correct Answer: C
Rationale: In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of their birth weight, making 3300 grams the expected weight for a 3600-gram newborn.
What symptom assessed in the newborn shortly after delivery should be reported?
- A. Cyanosis of the hands and feet
- B. Irregular heart rate
- C. Mucus draining from the nose
- D. Sternal or chest retractions
Correct Answer: D
Rationale: Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.
Which assessment of the newborn should be reported?
- A. Head circumference is 5 cm greater than the chest circumference.
- B. Hands and feet are warm with a blue color.
- C. Temperature is 36.6?°C (97.8?°F).
- D. Head has a longer than normal shape to it.
Correct Answer: A
Rationale: The circumference of the head should be less than 2 cm greater than that of the chest, and a 5 cm difference should be reported.