The nurse is performing an assessment of a 12-hour-old newborn. ...

[WWatsford]

The nurse is performing an assessment of a 12-hour-old newborn. Which finding(s) would require further action?
 
  a. Respirations 40, irregular, shallow
  b. Blood glucose 45 mg/dL
  c. Absence of bowel elimination since birth
  d. No urinary output since birth
  e. Episodic apnea lasting 25 seconds
  f. Jaundice on face and chest

Question 2

Which factor(s) aid(s) in the initiation of respiration in the neonate immediately following birth? (Select all that apply.)
 
  a. Touch
  b. Clamping of the umbilical cord
  c. Temperature change
  d. Hunger
  e. Light
  f. Anger

[vkodali]

Answer to Question 1

ANS: D, E, F
Voiding should occur within 8 hours of birth. Jaundice occurring within the first 24 hours of life is considered pathologic, rather than normal physiologic jaundice. Episodic apnea lasting less than 15 seconds is considered normal, but apnea lasting more than 20 seconds requires further assessment. The first stool is typically passed during the first 24 hours following birth. Respirations are expected to be between 30 and 60 per minute and may be irregular and shallow.

Answer to Question 2

ANS: A, B, C, E
There are four major categories of stimuli that send messages to the respiratory center of the neonate's brain to initiate respiration immediately after birth.
 Sensory: cold, touch, motion, light, sound.
 Chemical: clamping the cord.
 Thermal: temperature change (warm to cool).
 Mechanical: chest compression and recoil (expansion).
A neonate's lungs must function immediately after birth. Sensory stimuli of cold, touch, movement, light, and sound help respirations begin as the fetus emerges from the dark, warm uterus to the external environment. Clamping the cord causes temporary hypoxia, producing acidosis, which activates the respiratory center to initiate respirations. Temperature change from warm to cool stimulates respiration, but care must be taken to protect the neonate from excessive cold. The chest is compressed during passage through the birth canal, then recoils (expands) at the moment of birth.

[WWatsford]

TYSM

[isabelt_18]

Gracias!