The nurse is completing a respiratory assessment on a newborn. ...

[jjjetplane]

The nurse is completing a respiratory assessment on a newborn. What are normal findings of the assessment the nurse should document? (Select all that apply.)
 
  a. Periodic breathing
  b. Respiratory rate of 40 breaths/min
  c. Wheezes on auscultation
  d. Apnea lasting 25 seconds
  e. Slight intercostal retractions

Question 2

The nurse is conducting discharge teaching to parents regarding care of the umbilical cord. Which should the nurse include in the instructions? (Select all that apply.)
 
  a. Cover the umbilical cord with the diaper.
  b. The cord will fall off in 5 to 15 days.
  c. Clean around the umbilical cord stump with water.
  d. Watch for redness and drainage around the umbilical cord stump.
  e. A tub bath can be done every other day.

[steff9894]

Answer to Question 1

ANS: A, B, E
Periodic breathing is common in full-term newborns and consists of rapid, nonlabored respirations followed by pauses of less than 20 seconds. The newborn's respiratory rate is between 30 and 60 breaths/min. The ribs are flexible, and slight intercostal retractions are normal on inspiration. Periods of apnea lasting more than 20 seconds are abnormal, and wheezes should be reported.

Answer to Question 2

ANS: B, C, D
The umbilical cord is cleansed initially with sterile water or a neutral pH cleanser and then subsequently with water. The stump deteriorates through the process of dry gangrene, with an average separation time of 5 to 15 days. The umbilical cord area should be watched for redness or drainage, which could indicate infection. The diaper is placed below the cord to avoid irritation and wetness on the site, and tub bathing is not allowed until the umbilical cord falls off