The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first?

A) Newborn born at 37 weeks gestation. Respiratory rate of 45 breaths per minute.
B) Term newborn, 2 hours old, who has not passed a meconium stool.
C) Term newborn born yesterday. Heart rate is 150 beats per minute.
D) Term newborn born 1 hour ago who is exhibiting grunting respirations.


Answer: D

Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly immediate intervention. A normal respiratory rate is 30-60 breaths per minute. A normal pulse is 110-16 beats per minute. If a meconium stool is not passed within the first 24 hours, this would be cause for concern.

Nursing

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