Maternity Nursing Q 167
Immediately after birth, the nurse notes the following on a male newborn: respirations 78; apical heart rate 160 BPM, nostril-flaring; mild intercostal retractions; and grunting at the end of expiration. Which of the following should the nurse do?
A. Call the assessment data to the physician’s attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infant’s mouth and nares.
D. Recognize this as a normal first period of reactivity.
Correct Answer: D. Recognize this as normal first period of reactivity
The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period.
Option A: The infant’s assessment data reflect normal adaptation. Thus, the physician does not need to be notified.
Option B: Babies with heart or lung problems may need to breathe increased amounts of oxygen to get normal levels of oxygen in their blood. Oxygen therapy provides babies with extra oxygen.
Option C: The data do not indicate the presence of choking, gagging, or coughing, which are signs of excessive secretions. Suctioning is not necessary.