A nurse is monitoring a newborn infant who stops breathing for short periods when sleeping. The nurse should document that the infant is exhibiting periods of which finding?
Bradypnea
Eupnea
Dyspnea
Apnea
The Correct Answer is D
Choice A reason: Bradypnea refers to a respiratory rate that is slower than the normal range for the client's age group. In newborns, who typically breathe 30 to 60 times per minute, bradypnea would be a consistent slow rate, not a complete cessation of airflow for specific intervals during sleep.
Choice B reason: Eupnea is the medical term for normal, quiet, rhythmic breathing at a rate appropriate for the individual's developmental stage. Since the infant is experiencing pauses in their respiratory cycle, their breathing pattern is periodic or abnormal and cannot be documented as eupnea or healthy breathing.
Choice C reason: Dyspnea is the subjective sensation of difficulty breathing or "shortness of breath," often manifested objectively in infants as nasal flaring, grunting, or retractions. While apnea can lead to respiratory distress, the specific act of stopping breathing is defined by its cessation, not just the difficulty of the effort.
Choice D reason: Apnea is the clinical term for the temporary cessation of breathing. In newborns, periodic breathing is common, but true apnea involves pauses long enough to potentially cause bradycardia or cyanosis. Documentation must accurately reflect these "short periods" of no breathing to monitor for neonatal respiratory immaturity or underlying pathology.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The fifth intercostal space at the left midclavicular line is the anatomical landmark for the mitral valve area and the apical pulse. Auscultating here provides the best assessment of left ventricular function and the closure of the bicuspid valve, rather than the pulmonic valve located at the heart's base.
Choice B reason: The third intercostal space at the left sternal border is known as Erb's point. While this is a critical location for hearing heart sounds in general, particularly S2 and murmurs like aortic or pulmonic regurgitation, it is not the primary site for isolated pulmonic valve auscultation in a standard assessment.
Choice C reason: The second intercostal space left of the sternal border is the specific landmark for the pulmonic area. This site corresponds to the location where vibrations from the closure of the pulmonic semilunar valve are most audible as air and blood move from the right ventricle into the pulmonary artery.
Choice D reason: The second intercostal space right of the sternal border is the aortic area. This site is used to listen to the closure of the aortic semilunar valve. Placing the stethoscope here would emphasize the aortic component of the S2 heart sound rather than the pulmonic component.
Correct Answer is D
Explanation
Choice A reason: Vesicular breath sounds with equal intensity indicate normal, healthy lung parenchyma with clear alveolar air exchange. These sounds are soft and breezy, heard over most of the peripheral lung fields. The presence of equal vesicular sounds would contradict a diagnosis of atelectasis, which involves localized lung collapse.
Choice B reason: Loud bronchial breath sounds heard in the peripheral lung fields usually indicate consolidation, as seen in lobar pneumonia, where solid tissue conducts sound more efficiently than air-filled alveoli. While atelectasis involves collapsed tissue, the complete obstruction of the bronchus often prevents any sound from reaching the chest wall, resulting in silence.
Choice C reason: High-pitched wheezing is associated with bronchospasm or narrowed airways, typically found in asthma or chronic obstructive pulmonary disease. While wheezing can occur with partial collapse, bilateral lower lobe wheezing suggests a systemic or widespread airway issue rather than the localized collapse characteristic of a single-sided atelectasis.
Choice D reason: Atelectasis is the collapse of alveoli, which prevents air from entering that portion of the lung. Consequently, during auscultation, the nurse will note diminished or entirely absent breath sounds over the affected region because there is no air movement to generate the sound. Dullness to percussion is also typically noted.
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