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

Answer and Explanation

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.

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Correct Answer is A

Explanation

a) The younger child’s airways are smaller and more easily occluded: Children, especially infants, have smaller airways, making them more susceptible to blockage during infections.

b) You are incorrect in your assessment: This response dismisses the mother's concern without providing information.

c) Air passages are more likely to become blocked with mucus due to increased mucus production in young children: While increased mucus production can be a factor, the size of airways is a more critical consideration.

d) Infants are not able to breathe deeply: Not an accurate statement; infants have a different breathing pattern but can breathe adequately.

A. Obtaining a sweat chloride test B. Reproductive ability C. The effect of pancreatic enzymes on sex hormones D. Increased need for weight reduction diet

Correct Answer is B

Explanation

a) Obtaining a sweat chloride test: Likely already part of routine monitoring for cystic fibrosis.

b) Reproductive ability: Adolescents with cystic fibrosis may need education regarding how their condition can affect fertility.

c) The effect of pancreatic enzymes on sex hormones: Not a commonly discussed aspect in cystic fibrosis care.

d) Increased need for weight reduction diet: Weight maintenance or specific diets to promote weight gain are more commonly addressed in cystic fibrosis care.

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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?

Nursing Test Bank

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