Health Promotion and Maintenance
17. Which observation of an 8-pound, 4-ounce neonate, if made by an RN, would require an intervention?
Health Promotion and Maintenance
17. Which observation of an 8-pound, 4-ounce neonate, if made by an RN, would require an intervention?
. The neonate's respirations are 36, shallow, and irregular in rate, rhythm, and depth.
. The neonate's axillary temperature is 96.2°F (35.6°C).
. Rapid pulsations are visible in the fifth intercostal space, left midclavicular line.
. There is asynchronous spontaneous movement of the infant's extremities.
Test-Taking Tip
Identify which answers are within normal ranges for a neonate and eliminate these options.
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 these are normal findings in a neonate. Answer 2 is correct because this subnormal temperature indicates prematurity, infection, low environment temperature, inadequate clothing, and/or dehydration and requires an intervention. Answer 3 is incorrect because these are normal findings in a neonate. Answer 4 is incorrect because these are normal findings in a neonate.