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 assigning care?
Do not report any pause in respiration unless it's greater than 20 seconds
Report any neonate with nasal flaring
Report any pause in respiration greater than 10 seconds
Report any respiratory rate of 40 or greater
The Correct Answer is B
A. Do not report any pause in respiration unless it's greater than 20 seconds. Any pause in respiration can be significant in neonates. A pause in breathing, even if less than 20 seconds, should be reported, as it could indicate a potential problem. This option downplays the importance of monitoring respiratory patterns.
B. Report any neonate with nasal flaring. Nasal flaring in a neonate is a sign of respiratory distress. This instruction is essential because nasal flaring indicates the infant is working harder to breathe and may require further evaluation and intervention.
C. Report any pause in respiration greater than 10 seconds. While this is important, nasal flaring is a more immediate and visible sign of respiratory distress that should be reported.
D. Report any respiratory rate of 40 or greater. A respiratory rate of 40 breaths per minute is within the normal range for neonates. Reporting a normal rate would not be necessary and could create unnecessary concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F"]
Explanation
a) Eupnea: Normal breathing rate and pattern, not indicative of distress.
b) Apnea: Cessation of breathing, a sign of significant distress.
c) Tachypnea: Rapid breathing, often seen in respiratory distress.
d) Wheezing: High-pitched, musical sounds during expiration, suggesting airway obstruction.
e) Grunting: Heard during expiration, a sign of the body's attempt to keep air in the lungs, indicating distress.
f) Retractions: Visible sinking of tissues between ribs or at the sternum, indicating increased effort to breathe, a sign of distress.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
-
Coarctation of the aorta
Explanation: This condition involves a narrowing of the aorta, typically occurring just after the left subclavian artery. It causes higher blood pressure in the arms and lower blood pressure in the legs due to the obstruction of blood flow. -
Patent ductus arteriosus
Explanation: This is a condition where the ductus arteriosus, a blood vessel in the fetal heart, does not close after birth. It usually causes increased blood flow to the lungs rather than a discrepancy between upper and lower body blood pressures. -
Tetralogy of Fallot
Explanation: This congenital heart defect consists of four heart abnormalities. While it affects blood flow and oxygen levels, it does not typically cause a significant difference in blood pressure between the arms and legs. -
Transposition of the great arteries
Explanation: This condition involves the aorta and pulmonary artery being switched. It leads to severe oxygenation issues but does not usually result in a notable difference in blood pressure readings between the arms and legs.
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