A nurse assesses a neonate's respiratory rate at 46 bpm 6 hours after birth.
Respirations are shallow, with periods of apnea lasting up to 5 seconds.
Which action should the nurse take next?
Continue routine monitoring.
Attach an apnea monitor.
Follow respiratory arrest protocol.
Call the pediatrician immediately to report the finding.
The Correct Answer is A
Choice A rationale
A neonate's respiratory rate of 46 breaths per minute is within the normal range for a newborn, which is typically between 30 and 60 breaths per minute. Shallow respirations and brief periods of apnea lasting less than 20 seconds are also common in the immediate newborn period as the respiratory system adapts to extrauterine life. Therefore, continued routine monitoring is the appropriate initial action.
Choice B rationale
While apnea monitors are used for infants at high risk for apnea, such as preterm infants or those with known respiratory issues, a healthy term neonate with brief periods of apnea less than 20 seconds and a respiratory rate within the normal range does not typically require continuous electronic monitoring. This intervention would be premature given the current assessment findings.
Choice C rationale
Following a respiratory arrest protocol is indicated when a patient exhibits signs of respiratory distress or cessation of breathing. The neonate's current respiratory rate of 46 bpm, although shallow with brief pauses, does not indicate respiratory arrest. Initiating such a protocol would be an overreaction to the current assessment findings.
Choice D rationale
While it is important to keep the pediatrician informed about any significant changes in a neonate's condition, the findings described (respiratory rate of 46 bpm, shallow respirations, and apnea up to 5 seconds) are often normal in the first few hours after birth. Calling the pediatrician immediately for these findings alone is not the priority action; continued monitoring is more appropriate initially.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Unconjugation of bilirubin is the process where bilirubin, initially produced in a water-insoluble form (unconjugated or indirect bilirubin), is not yet processed by the liver. This form cannot be easily excreted by the body.
Choice B rationale
Albumin binding refers to the transport of unconjugated bilirubin in the bloodstream. Because unconjugated bilirubin is fat-soluble and not easily dissolved in water, it binds to albumin, a protein in the blood, which allows it to be transported to the liver.
Choice C rationale
The enterohepatic circuit describes the circulation of bile acids from the liver to the small intestine, where they aid in fat digestion and absorption, and then back to the liver. Bilirubin is a byproduct of heme breakdown and is processed separately in the liver before excretion in bile.
Choice D rationale
Conjugation of bilirubin is the process that occurs in the liver where the enzyme uridine diphosphoglucuronate glucuronosyltransferase (UGT) attaches glucuronic acid molecules to unconjugated bilirubin. This process transforms the fat-soluble unconjugated bilirubin into a water-soluble form called conjugated (or direct) bilirubin, which can then be excreted in bile into the intestines.
Correct Answer is B
Explanation
Choice A rationale
Wrapping the baby in warmed blankets addresses heat loss through conduction (direct contact with a cooler surface) and radiation (heat transfer to cooler surroundings). While helpful for maintaining warmth, it does not directly prevent heat loss from convection.
Choice B rationale
Convection is the loss of heat to cooler air currents moving across the skin surface. A blowing fan increases the rate of convective heat loss by continuously moving cooler air over the newborn. Moving the infant away from a blowing fan minimizes this heat transfer mechanism, thus preventing heat loss from convection.
Choice C rationale
Drying the baby after a bath primarily prevents heat loss through evaporation, as the evaporation of water from the skin surface cools the body. While important for thermoregulation, it does not directly address convective heat loss.
Choice D rationale
Placing the baby in a warmer, such as a radiant warmer, primarily prevents heat loss through radiation by providing a warm surface that emits infrared heat towards the infant. It also helps maintain the ambient air temperature, indirectly reducing convective heat loss, but moving away from a direct air current is the most direct way to prevent convection.
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