Which assessment finding of a newborn requires prompt action by the nurse?
A) Respiratory rate of 50 breaths per minute
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 per minute is still within the normal range. Tachypnea is considered to be 60 breaths per minute 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