any ideas on this one?

[wolf_funk]

any ideas on this one?

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.

[BSN2004NSU, BSN, RN]

A....because the resting heart rate should not be that high..

BSN2004NSU

[z's playa]

I had to look it up and yes the resting heart rate of a newborn should be 120-160 bpm (not 185) but the other ones don't sound too good either!!!

Welcome to NCLEX?

[HyperRNRachel]

B bulging anterior fontanel = increased intracranial pressure.

[happytobehere96]

B bulging anterior fontanel = increased intracranial pressure.

I would say A as well due to the heart rate. The hands and feet being blue I believe is normal in a neonate. I agree with the bulging fontanelle being a concern, but I believe I was told it can bulge when the child is crying. The respirations were fine and expected to be irregular, so definitely A I would say. But I am by no means an expert in pediatrics.

[*PICURN*]

definately A

B: the anterior fontanel is going to be bulging if the child is crying

C: nothing wrong, it is normal for the respirations to be irregular

D: hands and feet blue = acrocyanosis which is normal for l believe the first 12-24 hours?

[lilbiskit78]

Just thought I'd throw my 2 cents in, since I just finished OB last semester....it is most definately "A"....185 is way too high for resting HR....we must have the same text book, that exact question was on a CD-ROM that came with my book! I still remember something from last semester! YAY!

[wonderbee, BSN, RN]

I'll say B because there is something causing increased ICP.

[canoehead, BSN, RN]

C because what do they mean by irregular resps- guppy breathing, or your normal newborn stuff? Remember most pediatric codes are respiratory problems.

But the probable true correct answer is the 185bpm, although waiting 5min and checking it again might give you a totally different finding.

Both call for further assessment. A bulging fontanel while crying is OK, but why is the child crying so hard and not able to be soothed? If pt is consolable and hungry its OK.

D is a normal finding.

[DutchgirlRN, ASN, RN]

any ideas on this one?

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.

I would say "A". A heart rate of 185 is normal. If a NB baby is crying the anterior fontanel would and should be bulging. A 5 hour old baby normally has acrocyanosis of the hands and feet. Respirations of 45 are totally normal, irregular is normal. It doesn't say anything about retracting or grunting. I would say the answer is "A"

[LilRedRN1973]

I just had this question in my Kaplan book, I think. The answer is A....resting heart rate should not be that high. Bulging fontanel is due to the crying. Irregular respirations are very normal for a newborn, and acrocyanosis is also normal.

Melanie = )

[bsngrad02]

I've seen this question before someplace and the I'll have to agree with everyone who went with A.