A pediatric nurse is assigned telephone triage for the day at a ...

[tnt_battle]

A pediatric nurse is assigned telephone triage for the day at a pediatric clinic. The nurse receives a phone call from the mother of a newborn. The mother states, I am concerned about my baby.
 
  When she first goes to sleep, her eyes dart around under her eyelids, she doesn't breathe regularly, and she sometimes twitches. Based on this data, which response by the nuse is the most appropriate?
  A) Please bring your baby in immediately for a checkup.
  B) You should ask the doctor about these symptoms at your next checkup.
  C) These are common behaviors in newborns and are normal.
  D) If your baby does this again, take her to the emergency department.

Question 2

The nurse is caring for a client who is admitted to the hospital with a diagnosis of pneumonia. The client is on a monitor, and vital signs are recorded from the monitor in order to leave the client undisturbed during the night.
 
  The nurse observes that blood pressure, heart rate, and respirations are below baseline for this client. Based on this data, which conclusion by the nurse regarding the changes in vital signs is the most appropriate?
  A) The client is about to have a cardiac arrest.
  B) The client is in stage IV of NREM sleep.
  C) The client's metabolic rate has increased.
  D) The client is in stage II of NREM sleep.

[pangili4]

Answer to Question 1

Answer: C

These are indications of normal REM sleep in the newborn. The mother should be reassured that this is normal. Having the mother wait until the next checkup unnecessarily delays this reassurance. There is no need for an immediate trip to the clinic or to the emergency department.

Answer to Question 2

Answer: B

During stage IV sleep, the client is relaxed, and vital signs decrease from baseline by 20 to 30. Stage II sleep is characterized by light sleeping with vital signs decreasing slightly. The client's metabolic rate is decreased in stage IV. A decrease in vital signs is normal during stage IV sleep, and the client is not necessarily at risk for cardiac arrest.