What action should a nurse take if the respiratory rate of an infant is 35 breaths/minute?

Appeared in: RUHS, Jaipur, M.Sc Nursing Entrance Exam-2016

Explanation

The normal respiratory rate for an infant (1 to 12 months) is 30 to 60 breaths per minute.
A rate of 35 breaths/minute is a normal finding, indicating no respiratory distress is present.
The standard and appropriate nursing action for a normal, expected finding is to accurately record it in the patient's medical record for baseline data and communication.

Option A: Oxygen is a medical intervention for hypoxia or respiratory distress. A normal respiratory rate of 35 does not indicate a need for oxygen.
Option B: The physician should be notified of abnormal or critical findings. A normal respiratory rate is an expected finding and does not require immediate notification.
Option D: Immediate reassessment is not necessary for a stable and clearly normal finding. Routine monitoring will continue as scheduled, but there is no need for urgent re-evaluation.

Clinical Relevance

Nursing practice connection: Knowing Assessment of normal vital signs in infants helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Knowing age-specific vital sign parameters is a fundamental nursing responsibility to differentiate between normal findings and potential signs of illness.
Accurate documentation provides a legal record of care and a crucial baseline that allows other healthcare providers to track trends in the patient's condition.
What if? - If the infant's respiratory rate was 70 breaths/minute and accompanied by nasal flaring, the priority action would change to notifying the physician immediately and preparing for interventions like oxygen administration.

How to Approach the Question

First, identify the key information in the question: the patient is an infant, and the respiratory rate is 35 breaths/minute.
Next, recall the normal range for an infant's respiratory rate from your knowledge base.
Compare the patient's data (35 breaths/min) to the normal range (30-60 breaths/min).
Recognize that the value is within normal limits and there are no other signs of distress mentioned.
Finally, evaluate the given nursing actions. For a normal, stable finding, the most appropriate action is documentation. Eliminate interventions that are reserved for abnormal findings.

Concept Tested & Keywords

Concept Tested: Assessment of normal vital signs in infants
Stem keywords: infant, respiratory rate, 35 breaths/minute, nursing action
Lead-in keywords: What action
Clinical cues: Age/sex group narrows the expected diagnosis, intervention, or normal reference range.

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E6 Nursing Fundamentals Potter Perry 12e Part 3 p. 45-47

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