The nurse is caring for a newborn 30 minutes after birth. During an assessment of respiratory function, the following data are collected. Which of the following assessment findings would the nurse report as abnormal? Select all that apply
1. Respiratory rate of 66 breaths per minute
2. Periodic breathing with pauses of 25 seconds
3. Chest and abdomen movements are synchronous.
4. Grunting on expiration
5. Nasal flaring
6. Acrocyanosis
Correct
2; 4; 5
Rationale:
1. Immediately after birth and for the next 2 hours, normal respiratory rate is 60–70 breaths per minute. Abdominal movements that are synchronous with the chest movements are normal. Acrocyanosis is normal for several hours after birth.
2. Periodic breathing with pauses more than 20 seconds (apnea) is an abnormal finding that should be reported to the physician.
3. Immediately after birth and for the next 2 hours, normal respiratory rate is 60–70 breaths per minute. Abdominal movements that are synchronous with the chest movements are normal. Acrocyanosis is normal for several hours after birth.
4. Grunting on expiration is an abnormal finding that should be reported to the physician.
5. Nasal flaring is an abnormal finding that should be reported to the physician.
6. Immediately after birth and for the next 2 hours, normal respiratory rate is 60–70 breaths per minute. Abdominal movements that are synchronous with the chest movements are normal. Acrocyanosis is normal for several hours after birth.
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