A nurse is observing a 38-week gestation newborn in the nursery. ...

[dalyningkenk]

A nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations.
 
  The infant's color and heart rate remain unchanged. The nurse suspects that the infant:
 
  a. Is exhibiting signs of RDS.
  b. Requires tactile stimulation around the clock to ensure that apneic periods do not progress further.
  c. Is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit.
  d. Requires the use of CPAP to promote airway expansion.

Question 2

Which data should alert the nurse caring for an SGA infant that additional calories may be needed?
 
  a. The latest hematocrit was 53.
  b. The infant's weight gain is 40 g/day.
  c. The infant is taking 120 mL/kg every 24 hours.
  d. Three successive temperature measurements were 97, 96, and 97 F.

[mariahkathleeen]

Answer to Question 1

ANS: C
Periodic breathing can occur in term or preterm infants; it consists of periods of breathing cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths/min). It is not associated with any color or heart rate changes. Infants who exhibit this pattern should continue to be observed. There is no clinical evidence that the infant is exhibiting signs of respiratory distress syndrome (RDS). There is no indication that a pattern of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and tactile stimulation would be indicated if the infant were to have apneic spells.

Answer to Question 2

ANS: D
Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.