A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?
Newborns are abdominal breathers.
Activity will increase the respiratory rate.
The rate and rhythm of breath are irregular in newborns.
Newborns do not expand their lungs fully with each respiration.
The Correct Answer is C
Choice A) Newborns are abdominal breathers is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a characteristic of how newborns breathe. Abdominal breathing means that the diaphragm and the abdominal muscles are the main muscles used for breathing, rather than the chest muscles. Newborns are abdominal breathers because their chest wall is more compliant and less stable than adults, and their intercostal muscles are not fully developed. Abdominal breathing does not affect the accuracy or duration of measuring the respiratory rate, as long as the abdomen is visible and palpable. Therefore, this response is irrelevant and inaccurate.
Choice B) Activity will increase the respiratory rate is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a factor that can influence the respiratory rate. Activity means any physical or mental exertion that requires more oxygen and energy from the body. Activity can increase the respiratory rate, as well as the heart rate and blood pressure, to meet the increased oxygen demand and carbon dioxide removal. However, activity does not affect the accuracy or duration of measuring the respiratory rate, as long as the newborn is calm and resting during the measurement. Therefore, this response is irrelevant and inaccurate.
Choice C) The rate and rhythm of breath are irregular in newborns is correct because this is a reason why the respiratory rate should be counted for a complete minute. The rate and rhythm of breath refer to how fast and how regularly one breathes. Newborns have an irregular rate and rhythm of breath, which means that they breathe at different speeds and intervals, sometimes pausing for a few seconds between breaths. This is normal and harmless for newborns, as long as they do not stop breathing for more than 20 seconds or show signs of distress. However, it can make it difficult to measure the respiratory rate accurately, as counting for a shorter period may not reflect the true average rate. Therefore, counting for a complete minute can ensure a more reliable measurement. Therefore, this response is clear and accurate.
Choice D) Newborns do not expand their lungs fully with each respiration is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a feature of how newborns breathe.
Lung expansion means how much air one inhales and exhales with each breath. Newborns do not expand their lungs fully with each respiration, because they have smaller lung volumes and capacities than adults, and they breathe more shallowly and rapidly. However, lung expansion does not affect the accuracy or duration of measuring the respiratory rate, as long as the chest or abdomen movement is visible and palpable. Therefore, this response is irrelevant and inaccurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a) Ectopic pregnancy is incorrect because this is not a condition that requires delivery by cesarean section. Ectopic pregnancy is a condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. It is a life-threatening complication that can cause internal bleeding and rupture of the tube. Ectopic pregnancy cannot result in a viable baby and must be terminated as soon as possible, either by medication or surgery. Therefore, this response is irrelevant and inaccurate.
Choice b) Preeclampsia is incorrect because this is not a condition that always necessitates delivery by cesarean section. Preeclampsia is a condition where the blood pressure rises above 140/90 mmHg after 20 weeks of pregnancy, along with proteinuria and edema. It can cause complications such as eclampsia, HELLP syndrome, placental abruption, and fetal growth restriction. The only cure for preeclampsia is delivery of the baby and placenta, but the mode of delivery depends on several factors, such as the gestational age, the severity of the condition, the fetal status, and the maternal preference. Therefore, some women with preeclampsia may deliver vaginally, while
others may need a cesarean section.
Choice c) Partial abruptio placentae is incorrect because this is not a condition that always necessitates delivery by cesarean section. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, causing vaginal bleeding, abdominal pain, uterine contractions, and fetal distress. It can be classified as partial or complete, depending on the extent of the separation. The mode of delivery for abruptio placentae depends on several factors, such as the degree of bleeding, the fetal viability, the cervical dilation, and the fetal position.
Therefore, some women with partial abruptio placentae may deliver vaginally, while others may need a cesarean section.
Choice d) Total placenta previa is correct because this is the only condition that always necessitates delivery by cesarean section. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. It can be classified as marginal, partial, or total, depending on the degree of overlap. The mode of delivery for placenta previa depends on several factors, such as the type of previa, the amount of bleeding, the gestational age, and the fetal status. However, women with total placenta previa have no chance of delivering vaginally, as the placenta completely blocks the birth canal. Therefore, they must have a cesarean section to avoid hemorrhage and fetal compromise.
Correct Answer is C
Explanation
Choice a) Have the parent fold the infant's arms across the chest is incorrect because this is not a helpful way to calm a preterm infant. Folding the arms across the chest can restrict the infant's breathing and movement, and may increase their stress and discomfort. Preterm infants need gentle and supportive touch, not restraint or pressure.
Choice b) Encourage the parent to place the infant back in the warmer is incorrect because this is not a necessary or beneficial action for a preterm infant who is showing signs of overstimulation. Placing the infant back in the warmer can interrupt the bonding and attachment process between the parent and the infant, and may make the infant feel more isolated and insecure. Preterm infants need close and frequent contact with their parents, not separation or detachment.
Choice c) Encourage the parent to do kangaroo care is correct because this is an effective and evidence-based method of soothing and stabilizing a preterm infant who is experiencing overstimulation. Kangaroo care is a technique where the parent holds the infant skin-to-skin on their chest, providing warmth, comfort, and security. Kangaroo care can reduce the infant's stress hormones, lower their heart rate and blood pressure, improve their oxygenation and breathing, enhance their growth and development, and strengthen their bond with their parent.
Choice d) Cover the infant with a warm bed blanket is incorrect because this is not a sufficient or optimal way to comfort a preterm infant who is displaying signs of overstimulation. Covering the infant with a warm bed blanket can provide some warmth and protection, but it does not offer the same benefits as kangaroo care. A warm bed blanket cannot mimic the parent's heartbeat, voice, smell, and movement, which are essential for the infant's emotional and physiological well-being. Preterm infants need human touch and interaction, not just physical warmth.
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