A nurse is assessing a newborn immediately following a vaginal birth.
For which of the following findings should the nurse intervene?

The nurse should further evaluate respiratory characteristics and muscle tone to determine if the newborn is experiencing a complication.

Rationale for correct answers
Respiratory characteristics are critical to assess because irregular and shallow breathing in a newborn can indicate neurological or respiratory dysfunction. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with regular pattern; deviations may signal distress or central nervous system issues. Muscle tone evaluation is essential since increased tone with tremors suggests possible neurologic irritability or withdrawal. Normal newborn muscle tone should be moderate, neither hypotonic nor hypertonic, with symmetrical movement. These signs correlate with the high-pitched cry, tremors, and exaggerated reflexes noted, which may indicate neurological complications such as withdrawal syndrome or hypoxic-ischemic encephalopathy.

Rationale for incorrect answers
Heart rate (A) is important but was not reported abnormal; normal neonatal heart rate ranges from 120 to 160 beats per minute and the absence of murmurs suggests no cardiac compromise. Temperature (C) is less urgent as mucous membranes are moist and skin warm and dry, indicating stable thermoregulation; normal newborn temperature is 36.5–37.5°C. Feeding patterns (D) appear adequate with no difficulty reported, making this less immediately concerning.

Rationale for incorrect answers
Moro reflex (A) and Babinski reflex (B) are both present and exaggerated, which may be reactive but less specific for immediate concern than muscle tone abnormalities. Skin color (D) is normal without cyanosis or jaundice, reducing the likelihood of hypoxia or hemolytic issues.

Take home points

• Respiratory pattern irregularities in newborns may indicate neurological or respiratory dysfunction.
• Abnormal muscle tone and tremors are key signs of potential neurological complications.
• Normal heart rate, temperature, feeding, and skin color reduce likelihood of cardiac or systemic illness.
• Reflex exaggeration alone is less specific than muscle tone and respiratory changes for early complication detection.

Choice A rationale

While thermoregulation is critical for newborns, directly placing a newborn with an omphalocele under a radiant heat source without covering the exposed viscera first can lead to excessive fluid loss and potential hypothermia due to evaporation. The primary concern is protecting the exposed abdominal contents from injury and infection.

Choice B rationale

Positioning a newborn with an omphalocele in a supine position is generally appropriate, as it helps to keep the exposed viscera in a less compromised position. However, the most immediate and critical action is to protect the exposed organs from trauma, desiccation, and infection before considering positioning.

Choice C rationale

Using sterile plastic wrap to cover the viscera of a newborn with an omphalocele is a critical immediate nursing action. This creates a sterile barrier, prevents desiccation of the exposed abdominal contents, minimizes heat and fluid loss, and reduces the risk of infection, thus protecting the delicate organs until surgical repair.

Choice D rationale

Applying petroleum gauze to the exposed viscera is not the most appropriate or effective method for protecting an omphalocele. Petroleum gauze may stick to the delicate tissues, potentially causing trauma upon removal, and does not provide the same level of sterile barrier, moisture retention, or protection against environmental contaminants as sterile plastic wrap.