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What should the nurse do when an apnea monitor sounds an alarm 10 seconds after cessation of respirations?

1. Assess for changes in skin color

2. Use tactile stimuli on the chest or extremities

3. Check the monitor for signs of a malfunction

4. Resuscitate with a face mask and an Ambu bag (Nugent 331)
Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RNĀ® Examination, 7th Edition. Mosby, 2011. VitalBook file.

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Final answer:

When an apnea monitor alarms, a nurse should check for skin color changes, use tactile stimuli, check the monitor for malfunctions, and perform resuscitation with a mask and Ambu bag if necessary.

Step-by-step explanation:

When an apnea monitor sounds an alarm after 10 seconds of cessation of respirations, the nurse should immediately assess the situation.

The first action should be to quickly assess the infant for any visible changes, particularly checking for changes in skin color, which can indicate oxygen deprivation. If the skin color appears normal, the next step would be to provide tactile stimuli to the chest or extremities to stimulate breathing.

It is also essential to check the apnea monitor itself for any signs of malfunction to ensure the alert is valid.

Only if the infant remains unresponsive with no effective respirations or other life-threatening signs present, resuscitate the infant with a face mask and an Ambu bag.

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