Answer to Question 1
B
The developmental level of the newborn infant is consistent with the respiratory rate. A newborn's respiratory rate usually ranges from 40 to 60 breaths/min. Some references give an upper limit of 90 breaths/min. The rate gradually decreases with age until it reaches the normal adult rate of 12 to 20 breaths/min. The most appropriate action by the nurse is to document the findings and continue with the assessment. Placing the infant on oxygen is not warranted as this is a normal respiratory rate and there are no other issues warranting the need for oxygen. A call to the obstetrician is not needed. The nurse should not need to compare the finding with those of other infants, because she knows the norms for the developmental stage. Furthermore, the other infants may or may not have respirations within normal limits, so the comparison would not be helpful.
Answer to Question 2
A
Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or The Joint Commission.
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
Responsibilities of the nurse manager
When to measure vital signs
Measurement lenght of infant
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