The perinatal nurse notes that a newborn's respiratory rate is 68 breaths/minute. What actions by the nurse are appropriate? (Select all that apply.)
A.
Auscultating all lung fields (anterior and posterior)
B.
Documenting the infant's chest measurement
C.
Inspecting chest for skin color and retractions
D.
Notifying the physician of the assessment findings
E.
Withholding oral feedings while the infant is tachypneic
ANS: A, C, D, E
This respiratory rate is too fast. Appropriate actions include auscultating the lung fields, assessing the skin for color and the chest for retractions, withholding oral feedings until the infant's respiratory status has stabilized, and notifying the physician of the assessment findings. It is not necessary to document the chest measurement because of tachypnea.
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