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

Question

Quizplus · Accepted Answer

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.

Which Assessment Finding of a Newborn Requires Prompt Action by the Nurse