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) Carrots and green leafy vegetables: These are generally low in potassium and would be considered safer options for someone with hyperkalemia.
b) Spaghetti and meat sauce, breadsticks: These typically don't contain high potassium levels compared to other choices.
c) Hamburger on a bun, cherry gelatin: Unlikely to be high in potassium.
d) Chips, cold cuts, and canned foods: These can be high in added salts and preservatives, leading to higher potassium content. Therefore, they should be avoided by individuals managing hyperkalemia due to renal failure.
Correct Answer is ["A","C","D","E"]
Explanation
a) Airway swelling: Seen in both bronchiolitis and RSV due to inflammation.
b) Barking cough: More commonly associated with croup, not typically a prominent feature in bronchiolitis or RSV.
c) Increased mucus: Both conditions involve increased mucus production.
d) Bronchospasm: Present in both bronchiolitis and RSV due to airway irritation.
e) Air trapping: Can occur in both conditions due to the airway obstruction and inflammation
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