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