Health Promotion and Maintenance
39. A client delivers a 7-pound, 4-ounce neonate at 38 weeks' gestation. What observations, if found on initial assessment, should a nurse report to a physician? Select all that apply.
Health Promotion and Maintenance
39. A client delivers a 7-pound, 4-ounce neonate at 38 weeks' gestation. What observations, if found on initial assessment, should a nurse report to a physician? Select all that apply.
. Slight acrocyanosis.
. Respiratory rate of 20.
. Consistent heart rate of 145.
. Pilonidal dimple.
. Ecchymosis over the occiput.
Test-Taking Tip
Do not be distracted by the word "consistent," which in this case means consistently normal.
Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is incorrect because slight acrocyanosis, a bluish color of the extremities, is a benign, normal part of neonatal transition and is common during the first 24 to 48 hours after birth. It does not require any intervention, and does not need to be reported to the physician. Answer 2 is correct because the normal respiratory rate is 30 to 60 breaths/min. A rate of 20 is abnormal after birth and may indicate apnea and respiratory distress, and should be reported to the physician. Answer 3 is incorrect because a heart rate of 145 is in the normal range of 110 to 160, and does not need to be reported to the physician because it is within the normal limits for this infant. Answer 4 is correct because a pilonidal dimple may be a sign of spina bifida occulta, and requires further evaluation by a physician. Answer 5 is incorrect because ecchymosis (bruising) over the back of the fetal head is a normal finding related to the pressure of the presenting part on the fetal head resulting in bruising, and doesn't need to be reported to the physician.