Editing Maternal and Newborn Nursing – LPN Practice Questions (section)

==Question 3==
An LPN obtains vital signs on a 6-hour-old newborn. Which finding requires prompt reporting to the registered nurse?
# Axillary temperature 98.4 degrees F (36.9 degrees C)
# Heart rate 148 beats per minute while awake
# Respiratory rate 74 breaths per minute with grunting
# Blue hands and feet with a pink trunk and face

'''Answer:''' 3 (C). Respiratory rate 74 breaths per minute with grunting.

''Rationale:'' Normal newborn respirations are 30 to 60 per minute. A sustained rate above 60 combined with '''grunting''' indicates respiratory distress and must be reported immediately; other danger signs are nasal flaring, retractions, central cyanosis, and apnea longer than 20 seconds. Option 1 is within the normal axillary range of 97.7 to 99.5 degrees F. Option 2 is within the normal awake heart rate of 110 to 160. Option 4 describes acrocyanosis, a normal finding in the first 24 to 48 hours caused by immature peripheral circulation; '''central''' or circumoral cyanosis would be abnormal.