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Difficulty: HardAnte/Intra/Postpartum and Newborn Care

During morning rounds in the newborn nursery, a practical nurse collects data on a formula-fed neonate who is 18 hours old and was born at 37 weeks gestation. The infant's axillary temperature is 36.1°C (97.0°F), heart rate is 162 beats per minute, and respiratory rate is 70 breaths per minute with mild expiratory grunting. Which action is the priority for the practical nurse?

  1. Alert the registered nurse immediately and assist with placing the infant on a radiant warmer.Answer
  2. B
    Provide the scheduled formula feeding to prevent cold-induced hypoglycemia.
  3. C
    Swaddle the neonate in double blankets in the bassinet and reassess the vital signs in one hour.
  4. D
    Initiate peripheral intravenous access to prepare for anticipated antibiotic administration.

Answer

The priority action is to alert the registered nurse immediately and assist with placing the infant on a radiant warmer.
The correct answer addresses the urgent need for medical intervention while remaining safely within the practical nurse's scope of practice. Hypothermia in a neonate quickly leads to cold stress, which increases oxygen consumption and causes respiratory distress, evidenced here by tachypnea and grunting. Immediate registered nurse notification and active warming are essential.

Step-by-Step Solution

1
Analyze the collected data against normal neonatal parameters.
The temperature is below normal (hypothermia), heart rate is slightly elevated, and respiratory rate is significantly elevated with signs of increased work of breathing (grunting).
Identifying abnormal findings is the first step in determining clinical priority and recognizing physiological instability.
2
Evaluate the safety of routine interventions such as feeding or swaddling.
Feeding is determined to be unsafe due to the high respiratory rate (aspiration risk), and basic swaddling is insufficient for the severity of the distress.
Prioritizing Airway, Breathing, and Circulation (ABC) prevents the nurse from causing harm through contraindicated routine care.
3
Determine the appropriate action within the practical nursing scope of practice.
The nurse must escalate the findings to the registered nurse while assisting with immediate, non-invasive stabilization (radiant warmer).
Complex assessment and the initiation of advanced therapies require a registered nurse or provider.

Key Concept

Neonatal Cold Stress, Respiratory Distress, and Scope of Practice
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Topics

Ante/Intra/Postpartum and Newborn Care

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