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
A urinary output of 30 mL/hr is within the normal range for an adult, indicating adequate kidney perfusion and hydration status postpartum. Normal urine output is typically considered to be greater than 30 mL/hr.
Choice B rationale
Headache pain rated a 6 on a scale of 0 to 10 is a common complaint postpartum, especially after spinal anesthesia. While it requires assessment and management, it is not necessarily a sign of immediate life-threatening complication. Postpartum headaches can be related to hormonal shifts, dehydration, or the spinal anesthesia itself.
Choice C rationale
A blood pressure of 100/70 mm Hg is within the normal postpartum range for many women. While a decrease from pre-pregnancy levels can occur, this reading does not indicate an immediate critical issue. Normal postpartum blood pressure generally stabilizes around pre-pregnancy levels within a few days.
Choice D rationale
A respiratory rate of 10 breaths per minute is below the normal adult range of 12 to 20 breaths per minute. This bradypnea could indicate respiratory depression, a potential complication of spinal anesthesia, especially if opioid analgesics have been administered. Immediate intervention is required to assess the cause and ensure adequate oxygenation.
Correct Answer is D
Explanation
Choice A rationale
The ventrogluteal muscle, located in the hip, is a safe site for intramuscular injections in adults and children older than seven months due to its distance from major nerves and blood vessels. However, the vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns and infants due to its well-developed muscle mass and accessibility.
Choice B rationale
The deltoid muscle, located in the upper arm, is small and not well-developed in newborns, making it an unsuitable site for intramuscular injections. There is also a risk of injury to the brachial nerve and blood vessels in this area in neonates.
Choice C rationale
The dorsogluteal muscle, located in the buttocks, is no longer the recommended site for intramuscular injections in infants and young children due to the proximity of the sciatic nerve and major blood vessels, increasing the risk of nerve damage.
Choice D rationale
The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the recommended site for intramuscular injections in newborns. It is a large, well-developed muscle that is easily accessible and away from major nerves and blood vessels, making it a safe and effective site for administering vitamin K to prevent hemorrhagic disease of the newborn.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.