Which assessment findings would the nurse expect to find on a newborn who delivered 24 hours ago?

Correct Answer: B

Rationale: The correct answer is B: Heart rate of 145 beats per minute. This is expected in a newborn as their heart rate can range from 120-160 bpm. This indicates normal cardiac function. Choices A, C, and D are incorrect. A newborn's blood pressure is usually lower than 120/80. The normal temperature for a newborn is around 98.6-99.5°F. A respiratory rate of 62 breaths per minute is higher than normal for a newborn.

Correct Answer: B

Rationale: The correct answer is B: Suction the nose and then the mouth of the newborn to prevent aspiration. This is the most accurate statement because suctioning the nose first prevents any mucus or secretions from being pushed into the mouth during suctioning. Aspiration can occur if the baby inhales any secretions. Suctioning the mouth after the nose ensures that any remaining secretions are cleared. Choice A is incorrect because compressing the bulb syringe after insertion can cause trauma to the delicate nasal passages. Choice C is incorrect as using saline before suctioning is not necessary and may increase the risk of aspiration. Choice D is incorrect as placing the bulb syringe on the side of the infant's cheek is not an effective method for suctioning the mouth or nose.

Correct Answer: A

Rationale: The correct answer is A because larger labia minora relative to labia majora is a characteristic of preterm babies due to incomplete development. Labia minora being larger is a sign of immaturity in female infants. Choices B, C, and D are incorrect because plantar creases covering two-thirds of the foot, mostly absent lanugo, and ears with instant recoil are normal characteristics seen in full-term newborns. These features are signs of maturity and development, not indicators of prematurity.

Correct Answer: C

Rationale: The correct answer is C. Cesarean deliveries do not allow for thoracic squeeze of fluid. During vaginal delivery, the infant's thorax undergoes a squeezing motion which helps to expel the amniotic fluid from the lungs, reducing the risk of respiratory issues. In contrast, infants delivered via cesarean section do not experience this thoracic squeeze, potentially leading to a higher risk of respiratory problems. A is incorrect because infants delivered via cesarean section may actually have higher risks of transitional problems due to the lack of thoracic squeeze. B is incorrect as vaginal deliveries facilitate the natural process of clearing lung fluid. D is incorrect as vaginal deliveries are the preferred method for term infants when possible, as they provide various benefits for both the mother and the baby.

Correct Answer: B

Rationale: The correct answer is B: Heart rate of 180 bpm. A high heart rate in a newborn is concerning as it could indicate distress or a medical condition. A heart rate of 180 bpm is significantly above the normal range for a newborn (120-160 bpm), requiring immediate attention to assess and address the underlying cause, such as infection or cardiac issues. A: Capillary refill time of 3 seconds is within the normal range (less than 3 seconds is normal). C: Respiratory rate of 65 breaths per minute is slightly elevated but not as critical as a high heart rate. D: Apgar score of 8 at 5 minutes is a good score, indicating the baby is in overall good condition, but it does not address the immediate concern of a high heart rate.