Author Question: The nurse is performing an initial assessment of a newborn and notes retractions, nasal flaring, and ... (Read 78 times)

sammy · **on:** Jun 28, 2018

The nurse is performing an initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system?

a. Respiratory
b. Cardiovascular
c. Gastrointestinal
d. Musculoskeletal

Question 2

Which assessment finding of a newborn requires prompt action by the nurse?

a. Respiratory rate of 50 breaths/min
b. Cyanosis of the extremities
c. Pause in breathing lasting 20 seconds
d. Pause in breathing for 15 seconds followed by rapid respirations

cuttiesgirl16 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
Tachypnea, a respiratory rate of more than 60 breaths/min, is the most common sign of respiratory distress. Retractions occur when the soft tissue around the bones of the chest is drawn in with the effort of pulling air into the lungs. Xiphoid (substernal) retractions occur when the area under the sternum retracts each time the infant inhales. When the muscles between the ribs are drawn in so that each rib is outlined, intercostal retractions are present. A reflex widening of the nostrils occurs when the infant is receiving insufficient oxygen. Nasal flaring helps decrease airway resistance and increase the amount of air entering the lungs.

Answer to Question 2

ANS: C
Apnea is a pause in breathing lasting 20 seconds or more, or accompanied by cyanosis, pallor, bradycardia, and/or decreased muscle tone. Apnea is abnormal and requires prompt intervention. A respiratory rate of 50 breaths/min is still within the normal range. Tachypnea is considered to be 60 breaths/min or more. Cyanosis of the extremities or acrocyanosis is normal during the first day after birth and if the infant becomes cold. Periodic breathing is pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds. This occurs in some full-term infants during the first few days but is more common in preterm infants.