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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A practical nurse is collecting data on a newborn who was delivered at 38 weeks of gestation and is currently 16 hours old. Which of the following findings require immediate notification to the registered nurse (RN)? Select all that apply.

  1. Respiratory rate of 68 breaths per minute while resting quietlyAnswer
  2. Substernal retractions and nasal flaring during inspirationAnswer
  3. Yellowish discoloration of the skin on the face and upper chestAnswer
  4. D
    Bluish appearance of the hands and feet
  5. E
    Apical pulse of 135 beats per minute while awake
  6. F
    Audible mucus secretions pooling in the oral cavity

Answer

The findings that require immediate notification to the registered nurse are a resting respiratory rate of 68 breaths per minute, substernal retractions with nasal flaring, and yellowish discoloration of the skin.
A normal newborn respiratory rate is 30 to 60 breaths per minute; a rate of 68 at rest indicates tachypnea. Substernal retractions and nasal flaring are distinct indicators of respiratory distress. Both of these respiratory findings require immediate RN evaluation. Additionally, jaundice appearing within the first 24 hours of life is considered pathologic (often due to hemolysis) and requires immediate RN notification and further medical evaluation.

Step-by-Step Solution

1
Identify the normal vital signs and physiological expectations for a 16-hour-old newborn.
Normal respiratory rate is 30 to 60 breaths per minute, normal heart rate is 110 to 160 beats per minute, acrocyanosis is expected, and jaundice before 24 hours of age is abnormal.
Establishing normal baselines helps differentiate expected physiological findings from those requiring escalation.
2
Evaluate each assessment finding to determine if it is abnormal or a sign of complications.
The respiratory rate of 68, retractions, nasal flaring, and early-onset jaundice are abnormal findings.
Recognizing complications early ensures prompt intervention and prevents newborn deterioration.
3
Determine the appropriate practical nursing action for each abnormal finding.
The signs of respiratory distress and early jaundice require RN notification. Audible mucus requires immediate independent suctioning by the practical nurse before reporting.
The practical nurse must prioritize immediate airway clearance independently while escalating findings that require RN or provider assessment.

Key Concept

Prioritization of abnormal newborn assessment findings and boundary of practical nurse independent action.
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Topics

Ante/Intra/Postpartum and Newborn Care

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