The perinatal nurse teaches the student nurse about conditions that may require immediate investigation during the transitional period. These conditions include which of the following? (Select all that apply.)
A.
Grunting and sternal retractions
B.
Heart rate of 112 beats/minute
C.
Infant born at 36 + 2 weeks' gestation
D.
Respiratory rate of 62 breaths/minute
E.
The presence of nasal flaring
ANS: A, B, C, E
For infants, the normal heart rate is between 120 and 160 beats/minute. An infant who is less than 38 completed weeks' gestational age is considered preterm and should be assessed more frequently. An increased respiratory rate (60-70 breaths/minute) may represent a transitional period of adjustment to extrauterine life. However, the development of other symptoms such as nasal flaring, grunting, or intercostal retractions is indicative of respiratory distress.
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The next step of the nursing process following determination of an appropriate nursing diagnosis is the:
a. assessment phase. b. planning phase. c. implementation phase. d. evaluation phase.
A patient tells the nurse that he uses an active form of physical stimulation to decrease his pain. Which of the following is an active form of physical stimulation?
a. Tai chi c. shiatsu b. Swedish massage d. myofacial release
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