A nurse assesses a neonate's respiratory rate at 46 bpm 6 hours after birth.
Respirations are shallow, with periods of apnea lasting up to 5 seconds.
Which action should the nurse take next?
Continue routine monitoring.
Attach an apnea monitor.
Follow respiratory arrest protocol.
Call the pediatrician immediately to report the finding.
The Correct Answer is A
Choice A rationale
A neonate's respiratory rate of 46 breaths per minute is within the normal range for a newborn, which is typically between 30 and 60 breaths per minute. Shallow respirations and brief periods of apnea lasting less than 20 seconds are also common in the immediate newborn period as the respiratory system adapts to extrauterine life. Therefore, continued routine monitoring is the appropriate initial action.
Choice B rationale
While apnea monitors are used for infants at high risk for apnea, such as preterm infants or those with known respiratory issues, a healthy term neonate with brief periods of apnea less than 20 seconds and a respiratory rate within the normal range does not typically require continuous electronic monitoring. This intervention would be premature given the current assessment findings.
Choice C rationale
Following a respiratory arrest protocol is indicated when a patient exhibits signs of respiratory distress or cessation of breathing. The neonate's current respiratory rate of 46 bpm, although shallow with brief pauses, does not indicate respiratory arrest. Initiating such a protocol would be an overreaction to the current assessment findings.
Choice D rationale
While it is important to keep the pediatrician informed about any significant changes in a neonate's condition, the findings described (respiratory rate of 46 bpm, shallow respirations, and apnea up to 5 seconds) are often normal in the first few hours after birth. Calling the pediatrician immediately for these findings alone is not the priority action; continued monitoring is more appropriate initially.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Following a dilation and curettage (D&C) for a spontaneous miscarriage, the uterus needs time to heal. Resuming vaginal intercourse after approximately 2 weeks allows for some initial healing of the uterine lining and helps reduce the risk of infection. Healthcare providers typically advise waiting until bleeding has significantly decreased and discomfort has subsided.
Choice B rationale
While adequate nutrition is important for overall recovery after a miscarriage, there is no specific recommendation to increase the intake of zinc-rich foods in particular. A balanced diet supporting tissue repair is generally advised.
Choice C rationale
Aspirin is a salicylate and has antiplatelet properties. It is generally not recommended for managing cramps after a D&C due to the increased risk of bleeding. Acetaminophen or ibuprofen are typically preferred for pain relief.
Choice D rationale
Following a D&C for a spontaneous miscarriage, the products of conception have been removed from the uterus. While some vaginal bleeding is expected as the uterus heals, it should not contain identifiable fetal or placental tissue. Persistent passage of such tissue could indicate an incomplete evacuation or other complications requiring medical attention. .
Correct Answer is A
Explanation
Choice A rationale
Completely saturating a perineal pad within 15 minutes indicates excessive postpartum bleeding, which is most commonly caused by uterine atony (failure of the uterus to contract effectively after delivery). Massaging the fundus stimulates uterine muscles to contract, helping to compress blood vessels at the placental site and control bleeding. This is the priority intervention to prevent further blood loss and potential hemorrhage.
Choice B rationale
Assessing vital signs is important to evaluate the extent of blood loss and the woman's hemodynamic stability. However, the immediate priority is to address the cause of the excessive bleeding by promoting uterine contraction. Vital sign assessment should follow fundal massage.
Choice C rationale
Calling the primary health care provider is necessary to report the excessive bleeding and implement further management if fundal massage is not effective. However, the nurse's immediate action should be to address the likely cause of the bleeding through fundal massage.
Choice D rationale
Initiating an intravenous (IV) infusion of Ringer's lactate solution may be necessary to restore fluid volume if significant blood loss has occurred or continues. However, the immediate priority is to stop the bleeding by promoting uterine contraction through fundal massage. IV fluids are a subsequent intervention to support hemodynamic stability.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.