A nurse is collecting data from a newborn who is 12 hours old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?
Activate respiratory arrest procedures.
Request an order for supplemental oxygen.
Continue routine monitoring.
Report the observation to the charge nurse immediately.
The Correct Answer is C
Choice A rationale:
Activating respiratory arrest procedures is not necessary in this situation. The newborn's respiratory rate, although slightly elevated, does not indicate respiratory arrest. Instead, such procedures are reserved for situations where the newborn has stopped breathing or is in acute respiratory distress.
Choice B rationale:
Requesting an order for supplemental oxygen may be premature. The newborn's respiration rate of 44/min, although shallow with periods of apnea, is still within the normal range for a newborn. Providing supplemental oxygen should be considered when the newborn is showing signs of significant respiratory distress or if oxygen saturation levels are low.
Choice C rationale:
The most appropriate action in this scenario is to continue routine monitoring of the newborn's respiratory rate and overall condition. Newborns often exhibit irregular breathing patterns, including periods of apnea, especially in the first few hours after birth. As long as the newborn's color, heart rate, and overall appearance are stable, routine monitoring is appropriate.
Choice D rationale:
There is no need to report the observation to the charge nurse immediately, as the newborn's respiratory rate and pattern fall within the expected range for a 12-hour-old newborn.
Reporting should be considered when there are significant deviations from the norm or if the newborn's condition deteriorates.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"He is just cold”. is not the correct choice. While newborns can have cold hands and feet due to their immature thermoregulation, it would not explain persistent blue hands.
Choice B rationale:
"He may have been born with a heart problem”. is not the correct choice as it suggests a congenital heart defect. While cyanosis (bluish discoloration) can be associated with some heart problems, the hands alone being blue is less likely to be solely related to a heart issue.
Choice C rationale:
"The hands are always blue in a newborn”. is not the correct choice. While newborns may have bluish extremities (acrocyanosis) during the first few days after birth due to their developing circulatory system, persistent blue hands beyond this period would require further assessment.
Choice D rationale:
The correct choice is that "The circulation in his hands is not fully developed.”. Newborns have a developing circulatory system, and sometimes, their peripheral circulation takes some time to mature, leading to transient blue hands. However, if the blue color persists or worsens, it's essential to evaluate for any underlying issues.
Correct Answer is C
Explanation
Choice A rationale:
A respiratory rate of 22/min would be abnormally low for a newborn. The expected reference range for newborns is around 30-60 breaths per minute.
Choice B rationale:
A respiratory rate of 100/min would be abnormally high for a newborn. Such a high respiratory rate may indicate respiratory distress or other underlying issues and requires further evaluation.
Choice C rationale:
A respiratory rate of 48/min falls within the expected reference range for a newborn, which is around 30-60 breaths per minute. This rate suggests that the newborn's respiratory system is functioning within the normal range.
Choice D rationale:
A respiratory rate of 110/min would be abnormally high for a newborn. As mentioned earlier, the expected reference range for newborns is around 30-60 breaths per minute, making this rate concerning and necessitating further assessment.
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