[wolf_funk]

The nurse in the newborn nursery has just received report. Which of the following infants should the nurse see first?
A two-day-old infant is lying quietly alert with a heart rate of 185.

B one-day-old infant is crying and the anterior fontanel is bulging.

C 12-hour infant is being held; the respirations are 45 breaths per minute and irregular.

D five-hour-old infant is sleeping and the hands and feet are blue bilaterally.


can anybody answer this question plz?

[AmyB]

My answer would be A. The heart rate is too high. It is common for infants fontanelles to bulge when crying. The 12-hour infant's resps are normal for the given circumstance and age. And it's common (though I forget the name) for infants to have bilateral cyanosis (acrocyanosis?) in the extremities for the first 24-48 (?) hours after birth.

[weetziebat]

Yep, I agree. The correct response is A.

[wolf_funk]

Originally Posted by weetziebat

Yep, I agree. The correct response is A.

ped's and maternity not my best subjects lol RN here from uk in adult nursing , i gotta take the nclex to work in America. any adults question i am fine at lol, i know u all have taken it but some of the reasoning and questions and answers seem so obscure

[goldentxnurse]

A two-day-old infant is lying quietly alert with a heart rate of 185.
The heart rate should be between 110 – 150 w/o heart murmurs or signs of circulatory insufficiency. This is out of range, especially since the baby isn't crying or doing anything. I don't think this is normal.

B one-day-old infant is crying and the anterior fontanel is bulging.
It is normal to see the fontanels moving up and down as your baby feeds or cries. It should not look sunken or bulging at other times, so this is pretty much a normal thing.

C 12-hour infant is being held; the respirations are 45 breaths per minute and irregular.
The respiration rate is normal b/c it's supposed to be between 40 and 70, and I think it's common for the pattern to be irregular.

D five-hour-old infant is sleeping and the hands and feet are blue bilaterally.
Alright.. let me give you some of my rationales and see if this helps. Answer D is normal. It's common for the baby's hands and feet to be a blue-gray color in the first few days of life because the baby's circulatory system is not yet efficient at getting blood to these distant parts.

Ok. I'd personally go with A. It seems to me that the baby is in a little bit of distress. The only other one it could be with be would be C, b/c of the irregular thing. I wasn't sure the normal pattern, so i looked online to where they said it was common to be irregular, so that goes back to it being A again. I hope this helps, and that A is right. Is this a practice NCLEX question? I just took and passed boards. It's worded a bit like how they ask questions.

[wolf_funk]

yes it is a nclex questiondarn things do me head in lol

[goldentxnurse]

Originally Posted by wolf_funk

yes it is a nclex questiondarn things do me head in lol

haha When do you take the NCLEX? I only had 75 questions, but I felt like i wanted more. I seriously thought I failed it.