Which nursing action is appropriate when providing care to a newborn with a respiratory rate of 102 breaths per minute with lungs that are clear to auscultation?
1. Administering the bath to the neonate in the nursery
2. Transferring to the neonatal intensive care unit for further observation
3. Allowing the neonate to room-in to promote bonding
4. Providing the first feeding in the nursery
2
Explanation:
1. The newborn is tachypneic. Bathing will only add to the respiratory distress and should be avoided.
2. This newborn needs to remain under constant observation due to the respiratory rate.
3. The newborn needs to be monitored.
4. With a respiratory rate this high, aspiration is likely so feeding should be avoided.
You might also like to view...
You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations?
A) Place the patient in a room with roommates. B) Turn the lights to low illumination. C) Close closet doors. D) Leave the television on at all times.
Which of the following would the nurse expect to assess in a client diagnosed with postpartum psychosis?
A) Loss of pleasure B) Failed reality testing C) Feelings of hopelessness D) Lack of energy
A client's serum potassium level is 6.9 mEq/L. The nurse anticipates that the healthcare provider will order:
a. atropine. b. sodium bicarbonate (NaHCO3). c. insulin and glucose. d. sodium polystyrene sulfonate (Kayexalate) and sorbitol.
A patient comes to a clinic with a large, fluid-filled vesicle on his right hand. The nurse practitioner diagnoses cutaneous anthrax and prescribes an antibiotic
Which statement by the patient demonstrates a need for further teaching by the nurse? "I should anticipate a. being on this antibiotic for 60 days." b. that the area will be itchy, and I should not scratch it." c. that the lesion will scab over and fall off within 2 weeks." d. that I may develop a systemic infection."