Elevating Patient Care Through Comprehensive In-service Training
Elevating Patient Care Through Comprehensive In-service Training
The nursery nurse is performing assessments of several newborns. Which of the following findings are abnormal and need to be reported to the health care provider? Select all that apply.
Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory distress should be evaluated promptly to determine necessary treatment (Option 1).
Jaundice, especially in the first 24 hours of life (pathologic): Yellowish hues may be initially noted on the face or eyes and progress to the trunk and extremities (Option 4).
Although newborn jaundice after 24 hours of life is usually physiologic and resolves spontaneously, it should still be reported and monitored closely to ensure resolution.
No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth. Not voiding on the first day of life or in the past 24 hours is concerning for a structural anomaly or dehydration (Option 5).
Educational objective: When caring for newborns, the nurse should recognize abnormal findings (eg, jaundice, failure to void within 24 hours, signs of respiratory distress [eg, chest wall retractions]), and report them to the health care provider for further assessment.