Difficulty: Medium
Average Score: 81%
Simulated
Passage / Scenario
A newborn is 12 hours old and was born at 37 weeks gestation. The nurse notes that the newborn has a respiratory rate of 74/min, with mild retractions and nasal flaring. The newborn├óÔé¼Ôäós heart rate is 170/min, and the temperature is 36.7├é┬░C (98.1├é┬░F). The nurse also observes grunting and cyanosis around the mouth.Select the 3 findings that require immediate follow-up.
Correct answer
B,C,D
Rationale
B: Respiratory rate of 74/min indicates potential distress. C: Heart rate of 170/min suggests tachycardia. D: Retractions, nasal flaring, and grunting indicate respiratory distress.