A nurse delegates the task of infant vital sign assessment to a nurse technician. The nurse should instruct the technician to:
1. Report any infant using abdominal muscles to breathe.
2. Report any infant with a breathing pause that lasts 10 seconds or less.
3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute.
4. Report any infant with a breathing pause that lasts 20 seconds or longer.
4
Rationale:
1. It's normal for infants to use abdominal muscles for breathing.
2. A breathing pause of 10 seconds or less is called periodic breathing, and is a normal pattern for an infant.
3. Respirations should be counted for 1 minute, not 15 seconds.
4. The abnormal assessment finding for vital signs the nurse should instruct a nurse technician to report is any breathing pause by an infant lasting longer than 20 seconds. This can indicate apnea, and could lead to an apparent life-threatening event (ALTE).
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