The nurse is obtaining vital signs on a newborn infant and notes respirations at 56 breaths/min. What is the most appropriate action by the nurse?

Question

a. Apply oxygen immediately.
b. Document the finding and continue the assessment.
c. Contact the obstetrician for orders.
d. Compare the finding with other infants in the nursery.

Answer 1

B
The developmental level of the newborn infant is consistent with the respiratory rate. A newborn's respiratory rate usually ranges from 40 to 60 breaths/min. Some references give an upper limit of 90 breaths/min. The rate gradually decreases with age until it reaches the normal adult rate of 12 to 20 breaths/min. The most appropriate action by the nurse is to document the findings and continue with the assessment. Placing the infant on oxygen is not warranted as this is a normal respiratory rate and there are no other issues warranting the need for oxygen. A call to the obstetrician is not needed. The nurse should not need to compare the finding with those of other infants, because she knows the norms for the developmental stage. Furthermore, the other infants may or may not have respirations within normal limits, so the comparison would not be helpful.