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.

Nursing

You might also like to view...

Which is a safety measure for making beds?

a. Lower the bed for body mechanics. b. Wear gloves when removing linen from the person's bed. c. After making a bed, raise the bed to its highest position. d. After making an occupied bed, never raise the bed rails.

Nursing

A nurse who is providing diabetes screening at a community clinic discovers that a new client has type 2 diabetes mellitus. The nurse provides counseling, refers the client to an endocrinologist for initial assessment and treatment,

arranges for the client to see someone regarding financial assistance, contacts the mobile van to arrange transportation, and sets up a follow-up appointment. Which of the following types of service do these actions represent? a. Case management b. Client advocacy c. Holistic care d. Wrap-around services

Nursing

The nurse makes a medication error. The nurse manager determines the error was based on a common misinterpretation of which abbreviation?

1. IU 2. SQ 3. Q.O.D. 4. U 5. mcg

Nursing

Individuals who receive care in a long-term care facility are called ____________________.

Fill in the blank(s) with the appropriate word(s).

Nursing