The perinatal nurse is aware that if a respiratory rate of 68 breaths per minute is noted in the newborn, the appropriate nursing actions would include:
Select all answers that apply.
A) withholding the feeding.
B) continuing assessment of the infant's respiratory rate and color.
C) notifying the physician of additional signs or symptoms of respiratory distress.
D) documenting the infant's chest measurement.
Question 2
The perinatal nurse is providing care to Carolyn, a 17-year-old woman, G2 TPAL 0010, who has been admitted because of an antenatal hemorrhage. An ultrasound examination confirms that she is experiencing an abruptio placentae.
Carolyn's vital signs include the following: blood pressure = 110/66, Pulse = 92; respirations = 18 breaths/minute. The fetal heart rate is 156 bpm and is being continuously monitored. An additional element of nursing care would be:
A) Hourly assessment of vital signs
B) Assessment of the perineum every 15 minutes for evidence of bleeding
C) Assessment of intake and output every 8 hours
D) Blood work that includes a complete blood count (CBC), prothrombin time, and serum electrolytes
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