The nurse is caring for a newborn with rapid respirations. How would the nurse get an accurate respiratory rate?
1. Remove the client's clothing so the chest movement can be seen.
2. Count respirations for 30 seconds and multiply by two.
3. Place the hand on the client's back to feel the respirations.
4. Use a stethoscope to hear respirations.
Correct Answer: 4
The nurse would be able to get the most accurate respiratory rate in an infant who is breathing quickly by using a stethoscope. Removing clothes will allow the nurse to see chest movement, but when the infant is undressed, he might begin crying, which would alter the respiratory rate. Placing a hand on the infant's back would allow the nurse to feel most respirations, but would not yield as accurate an assessment as would the use of the stethoscope.
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