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 D
Explanation
a) Hyperthermia: Hyponatremia can disrupt temperature regulation, but it doesn't typically cause hyperthermia directly.
b) Respiratory distress: While severe cases might cause neurological issues affecting breathing, it's not the primary concern in hyponatremia.
c) Bradycardia: Though possible due to neurological complications, it's not the primary issue to anticipate in hyponatremia.
d) Seizure: Hyponatremia significantly affects brain function due to electrolyte imbalance, predisposing the child to seizures.
Correct Answer is D
Explanation
a) Pulmonary constriction: Typically, not associated with tracheal deviation or air in the pleural space.
b) Smoke inhalation injury: Unlikely to cause tracheal deviation or air in the pleural space.
c) Pneumonia: Does not typically cause tracheal deviation or immediate hypotension.
d) Tension pneumothorax: Presents with air in the pleural space, tracheal deviation, respiratory distress, decreasing LOC, and can lead to hypotension due to compromised circulation.
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