A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
Rust-stained urine.
Single palmar creases.
Subconjunctival hemorrhage.
Transient circumoral cyanosis
The Correct Answer is B
The correct answer is choice B. Single palmar creases.
Choice A rationale:
Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.
Choice B rationale:
Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.
Choice C rationale:
Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.
Choice D rationale:
Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.
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Related Questions
Correct Answer is A
Explanation
This is because a low pulse oximetry reading can indicate that the newborn is hypoxic and needs suctioning of the nasopharynx to clear any secretions that may be obstructing the airway²⁴. Hypoxia can cause bradycardia, acidosis, and brain injury in newborns, and should be corrected as soon as possible². The normal range of pulse oximetry for a newborn is 95% to 100%².
The other options are not correct because:
b) The newborn's respiratory rate is irregular
This is not a sign that suctioning is needed, as it is a normal finding in newborns. Newborns have periodic breathing patterns, which involve alternating periods of rapid and slow breathing, with occasional pauses of up to 10 seconds². This does not indicate respiratory distress or hypoxia, and does not require intervention unless the pauses are longer than 10 seconds or associated with cyanosis or bradycardia².
c) The newborn is beginning to cough
This is not a sign that suctioning is needed, as it is a normal reflex that helps the newborn clear the airway of secretions. Coughing can also stimulate breathing and prevent apnea in newborns². Coughing does not indicate respiratory distress or hypoxia, and does not require intervention unless it is persistent or associated with other signs of respiratory compromise².
d) The newborn's respiratory rate is 32/min
This is not a sign that suctioning is needed, as it is within the normal range for a newborn. The normal respiratory rate for a newborn is 30 to 60 breaths per minute². A respiratory rate that is too high or too low can indicate respiratory distress or hypoxia, and may require suctioning or other interventions².
Correct Answer is D
Explanation
Heart rate is one of the vital signs that reflects the health and well-being of a newborn. It is measured by counting the number of heart beats per minute, either by listening to the chest with a stethoscope or by feeling the pulse at the wrist, elbow, or groin. Heart rate can vary depending on the newborn's activity level, temperature, and emotional state¹.
The normal range for heart rate in full-term newborns is 120 to 160 beats per minute. The heart rate may be slightly higher or lower depending on the newborn's age, weight, and gestational age. For example, premature newborns may have a higher heart rate than term newborns, and heavier newborns may have a lower heart rate than lighter newborns¹².
A heart rate that is too high (tachycardia) or too low (bradycardia) can indicate a problem with the newborn's heart function, oxygenation, or circulation. Some of the possible causes of abnormal heart rate in newborns are:
- Congenital heart defects: structural abnormalities of the heart that are present at birth and affect the blood flow through the heart and the body. They can cause cyanosis (bluish skin color), murmur (abnormal heart sound), poor feeding, or failure to thrive¹³.
- Arrhythmias: irregular or abnormal heart rhythms that can affect the electrical impulses that control the heartbeat. They can cause palpitations (feeling of skipped or extra beats), dizziness, fainting, or cardiac arrest¹³.
- Hypoxia: lack of oxygen in the blood or tissues that can affect the brain and other organs. It can be caused by respiratory distress, anemia, infection, or birth asphyxia. It can cause bradycardia, apnea (pauses in breathing), seizures, or coma¹⁴.
- Hypothermia: low body temperature that can affect the metabolism and organ function. It can be caused by exposure to cold environment, infection, or prematurity. It can cause bradycardia, lethargy, poor feeding, or hypoglycemia (low blood sugar)¹⁴.
- Sepsis: severe infection that can affect the whole body and cause inflammation and organ damage. It can be caused by bacteria, viruses, fungi, or parasites that enter the bloodstream from the mother, the umbilical cord, or the environment. It can cause tachycardia, fever, chills, poor feeding, or shock¹⁴.
Therefore, the nurse should report a heart rate of 72/min to the provider as an abnormal finding and monitor the newborn for any other signs of distress or illness. The provider may order further tests or treatments to determine the cause and severity of the low heart rate and prevent any complications.
The other findings are not findings that the nurse should report to the provider because they are within the
normal range for full-term newborns:
- a) Respiratory rate 55/min is within the normal range for respiratory rate in full-term newborns. The normal range for respiratory rate in full-term newborns is 40 to 60 breaths per minute. The respiratory rate may vary depending on the newborn's activity level, temperature and emotional state¹².
- b) Blood pressure 80/50 mm Hg is within the normal range for blood pressure in full-term newborns. The normal range for blood pressure in full-term newborns is 65 to 95 mm Hg for systolic pressure (the top number) and 30 to 60 mm Hg for diastolic pressure (the bottom number). The blood pressure may vary depending on the newborn's age, weight, and gestational age¹².
- c) Temperature 36.5°C (97.7°F) is within the normal range for temperature in full-term newborns. The normal range for temperature in full-term newborns is 36.5°C to 37.5°C (97.7°F to 99.5°F). The temperature may vary depending on the newborn's activity level, clothing, and environment¹².
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