CCNS Certified Clinical Nurse Specialist

Category - Neonatal

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A nurse is caring for a newborn patient in the neonatal intensive care unit. She notified the physician because she was able to assess a:

Body temperature of 97.7°F
Pale pink, rust colored stain in the diaper
Cardiac rate that drops to 112 beats per minute
Breathing pattern that is diaphragmatic with sternal retractions

Explanation

Answer - D - She notified the physician because she was able to assess a breathing pattern that is diaphragmatic with sternal retractions. The assessment result is indicative of respiratory distress; the expected pattern is abdominal with synchronous chest movement.

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