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) Urine output of 200 mL for the past 8 hours is incorrect because this is a normal finding for a postpartum woman. The average urine output for a healthy adult is about 800 to 2000 mL per day, which means about 100 to 250 mL per hour. Therefore, a urine output of 200 mL for the past 8 hours is within the normal range and does not indicate any complications.
Choice b) Weight decrease of 2 pounds since delivery is incorrect because this is also a normal finding for a postpartum woman. The weight loss is due to the expulsion of the placenta, amniotic fluid, and blood during delivery. A postpartum woman can expect to lose about 10 to 12 pounds immediately after giving birth, and another 5 pounds in the following weeks due to fluid loss. Therefore, a weight decrease of 2 pounds since delivery is not a cause for concern and does not need to be reported to the obstetrician.
Choice c) Pulse rate of 65 beats per minute is incorrect because this is also a normal finding for a postpartum woman. The normal resting pulse rate for an adult ranges from 60 to 100 beats per minute, and it may decrease slightly after delivery due to blood loss and reduced cardiac output. Therefore, a pulse rate of 65 beats per minute is not indicative of any problems and does not require any intervention.
Choice d) Drop in hematocrit of 6% since admission is correct because this is an abnormal finding for a postpartum woman and suggests that she has developed anemia due to excessive blood loss. Hematocrit is the percentage of red blood cells in the blood, and it reflects the oxygen-carrying capacity of the blood. The normal hematocrit range for an adult female is 37% to 47%, and it may decrease slightly after delivery due to hemodilution. However, a drop in hematocrit of more than 10% from the baseline or below 30% indicates severe anemia and requires immediate treatment. Therefore, a drop in hematocrit of 6% since admission is a significant change that should be reported to the obstetrician as soon as possible.
Correct Answer is B
Explanation
Choice A) "Oh, don't worry about that. It's okay." is incorrect because this is not a helpful or informative response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not explain what the black, sticky stuff in the diaper is, why it is there, or how long it will last. It also does not address the father's concern or curiosity, and may make him feel dismissed or ignored. Therefore, this response is inadequate and inappropriate.
Choice B) "That's meconium, which is your baby's first stool. It's normal." is correct because this is a clear and accurate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response explains what the black, sticky stuff in the diaper is, which is meconium. Meconium is a substance that consists of amniotic fluid, mucus, bile, and other waste products that accumulate in the baby's intestines before birth. It is usually passed within the first 24 to 48 hours after birth, and then replaced by transitional or regular stools. Meconium has a dark green or black color and a thick, sticky consistency. It does not have any odor or bacteria. It is normal and harmless for most babies, unless they inhale it during delivery, which can cause breathing problems or infection. Therefore, this response reassures and educates the father about his baby's condition.
Choice C) "That's transitional stool." is incorrect because this is not a true or complete response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not identify what the black, sticky stuff in the diaper is, which is meconium. Transitional stool is a type of stool that appears after meconium and before regular stools. It usually occurs between the second and fifth day after birth, and then changes to yellow or brown stools. Transitional stool has a greenish-brown color and a loose, seedy consistency. It may have some odor or bacteria. It indicates that the baby's digestive system is maturing and adapting to breast milk or formula. Therefore, this response confuses and misleads the father about his baby's condition.
Choice D) "That means your baby is bleeding internally." is incorrect because this is not a valid or appropriate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not describe what the black, sticky stuff in the diaper is, which is meconium. Bleeding internally means that blood vessels are damaged or ruptured inside the body, causing blood loss and shock. This can be caused by various factors such as trauma, infection, clotting disorder, or medication. Bleeding internally can manifest as blood in the stool, urine, vomit, or saliva. However, it does not cause black, sticky stools like meconium. Moreover, this response scares and alarms the father without any evidence or reason. Therefore, this response is false and unethical.
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