A nurse working in the newborn nursery notes that an infant is having frequent episodes of apnea lasting 10 to15 seconds without any changes in color or decreases in heart rate. Which intervention would be the most appropriate?
1. Continue to observe the infant and call the physician if the apnea lasts longer than 20 seconds.
2. Suction the infant's mouth and nares.
3. Call the physician immediately.
4. Turn the infant on its right side.
1
Rationale 1: Apnea lasting less than 20 seconds is a normal finding in newborns as long as there is no associated cyanosis or bradycardia, so continued observation is the most appropriate intervention.
Rationale 2: There is no indication that suctioning is needed.
Rationale 3: It is unnecessary to inform the physician, as apnea lasting 10 to 15 seconds is normal in a newborn.
Rationale 4: Turning the baby is not necessary, as apnea lasting 10 to 15 seconds in a newborn is normal.
Global Rationale:
You might also like to view...
Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which statement regarding a client's home environment should a nurse associate with the development of anorexia nervosa?
1. The home environment maintains loose personal boundaries. 2. The home environment places an overemphasis on food. 3. The home environment is overprotective and demands perfection. 4. The home environment condones corporal punishment.
Mastoiditis and labyrinthitis are potential complications of otitis media
Indicate whether the statement is true or false
With which client is it most important for the nurse to take special precautions because of an increased susceptibility to infection as a result of medical therapy?
A. The 38-year-old woman taking contraceptives B. The 38-year-old man with diabetes mellitus taking insulin C. The 58-year-old man 5 years after a myocardial infarction taking aspirin daily D. The 58-year-old woman with rheumatoid arthritis taking corticosteroids daily
After therapy with methotrexate the tetrahydrofolate pool in the host's cells is often depleted . The pool can be partially replenished through administration of :
A. B complex vitamins B. Iron C. Leucovorin D. Mesna