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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse is performing an assessment on a 2-hour-old newborn. Which of the following findings requires immediate intervention by the nurse?

  1. Respiratory rate of 68 breaths per minute with intercostal retractionsAnswer
  2. B
    Irregular breathing pattern with pauses lasting up to 15 seconds
  3. C
    Apical heart rate of 115 beats per minute while the newborn is sleeping
  4. D
    Presence of a bluish-gray pigmented area over the sacral region

Answer

The finding of a respiratory rate of 68 breaths per minute with intercostal retractions requires immediate intervention.
A respiratory rate of 68 breaths per minute (tachypnea) accompanied by intercostal retractions is a classic sign of respiratory distress in the newborn. Normal newborn respiratory rates range from 30 to 60 breaths per minute. According to the ABCs (Airway, Breathing, Circulation) of prioritization, this respiratory compromise is the highest priority and requires immediate medical intervention.

Step-by-Step Solution

1
Analyze each assessment finding against normal newborn physiological parameters.
Three of the findings are normal transitional or expected variations, while one indicates a deviation from normal.
Differentiating between normal variations and signs of pathology is essential for accurate clinical judgment.
2
Apply the ABC (Airway, Breathing, Circulation) framework to prioritize the abnormal findings.
The tachypnea (respiratory rate > 60) and intercostal retractions indicate a breathing compromise, identifying it as the highest priority.
Respiratory distress can rapidly lead to hypoxia and deterioration in a newborn if not addressed immediately.

Key Concept

Identifying signs of respiratory distress in the newborn and differentiating them from normal physiological transitions.
Estimated Time:1m 0s
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Topics

Ante/Intra/Postpartum and Newborn Care

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