The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first?
1. 37-week male, respiratory rate 45
2. 8 pound 1 ounce female, pulse 150
3. Term male, grunting respirations
4. 4-hour-old female who has not voided
3
Rationale 1: A normal respiratory rate is 30–60 breaths/min. This infant has no unexpected findings.
Rationale 2: A normal pulse is 110–160 beats/min. This infant has no unexpected findings.
Rationale 3: Grunting respirations are an indication of respiratory distress. This infant needs further assessment, and possibly intervention, immediately.
Rationale 4: Most infants void within the first 24 hours of life, but this is not a life-threatening condition.
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