Practice Quiz

CCNS Certified Clinical Nurse Specialist

Category - Neonatal

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A nurse is assigned in caring for newborn patients admitted at the neonatal intensive care unit. The nurse should immediately refer a patient who has:
  1. Cardiac rate that drops to 110 beats per minute
  2. Immature kidneys with evidence of rust-colored stain in the diaper
  3. Body temperature of 97.8°F
  4. Respiratory rate of 25 beats per minute with sternal retractions
Explanation
Answer - D - The nurse should immediately refer a patient who has a respiratory rate of 25 beats per minute with sternal retractions. A respiratory rate of 25 beats per minute and abnormal breathing pattern is indicative of respiratory distress. Among newborns, the expected breathing pattern is abdominal with synchronous chest movement.
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