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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

During morning rounds in the normal newborn nursery, a practical nurse evaluates a 6-hour-old term neonate delivered at 39 weeks of gestation. The infant's current axillary temperature is 97.2°F (36.2°C) and the respiratory rate is 68 breaths per minute. The nurse also notes the presence of mild expiratory grunting. Which of the following actions should the nurse take first?

  1. Report the vital signs and physical findings to the supervising registered nurse immediately.Answer
  2. B
    Document the clinical findings in the medical record as expected transitional behavior.
  3. C
    Wrap the infant in two warm blankets and reassess the temperature in one hour.
  4. D
    Conduct a comprehensive clinical assessment to determine the underlying cause of the distress.

Answer

The practical nurse should immediately report the vital signs and physical findings to the supervising registered nurse.
The correct action is to promptly notify the supervising registered nurse because the neonate's vital signs and grunting indicate respiratory distress and cold stress. Recognizing these acute abnormalities and escalating the information ensures the infant receives appropriate, timely medical interventions, which perfectly aligns with the practical nurse's scope of practice.

Step-by-Step Solution

1
Analyze the neonate's vital signs and physical assessment data.
The temperature of 97.2°F (36.2°C) is abnormally low, and the respiratory rate of 68 breaths/minute with grunting indicates respiratory distress.
Normal newborn temperature ranges from 97.7°F to 99.5°F (36.5°C to 37.5°C), and normal respiratory rate is 30 to 60 breaths/minute.
2
Determine the priority of care based on the Airway, Breathing, Circulation (ABC) framework.
The abnormal respiratory findings take immediate priority over routine care or solely addressing the hypothermia.
Respiratory distress in a neonate can quickly lead to hypoxia and further physical deterioration.
3
Identify the appropriate action within the practical nurse's scope of practice.
The nurse must escalate the critical findings to the registered nurse for advanced assessment and collaborative intervention.
Practical nurses are responsible for gathering data, recognizing abnormal findings, and reporting them to the supervising RN or provider for timely medical management.

Key Concept

Recognizing signs of neonatal respiratory distress and adhering to the practical nurse's scope of practice by reporting abnormal findings.
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Topics

Ante/Intra/Postpartum and Newborn Care

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