The nurse is caring for a group of 1-day-old clients in the newborn nursery. Which finding requires immediate attention?

Question

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Newborns normally have respirations of 30-60/min, with periodic pauses lasting <20 seconds. Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium aspiration, or infection (Option D). The newborn should be placed on continuous monitoring and may require respiratory support (eg, oxygen, continuous positive airway pressure) until the underlying cause is corrected and respiratory status stabilizes. (Option A) Common characteristics of normal newborn respiratory patterns may include shallow, irregular, or abdominal respirations. (Option B) The apical heart rate should be counted for a full minute and is normally 100-180/min. Stimulated states (eg, crying, activity) may cause increased heart rate, respirations, and blood pressure. The nurse should reassess vital signs when the newborn is calm. (Option C) A physiologic heart murmur is expected in the first 48 hours of life during transition from fetal to neonatal circulation. Newborns with congenital heart disease have a pathologic heart murmur associated with other assessment findings (eg, abnormal vital signs, cyanosis, poor feeding). Educational objective: The normal respiratory rate and pattern for newborns is 30-60/min with periodic pauses lasting <20 seconds. Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory distress may be related to retained amniotic fluid in the lungs, meconium aspiration, or infection.

The Nurse Is Caring for a Group of 1-Day-Old Clients