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A nurse is caring for a newborn.

Exhibits

Which of the following assessment findings require follow-up by the nurse?

Click to highlight the statements in the assessment findings that require follow-up by the nurse.

Axillary temperature 36.1° C (97° F)

Heart rate 160/min

Respiratory rate 78/min

Newborn is sleeping in their birth parent's arms. Awakens with stimulation. Yellow discoloration noted of sclera and oral mucosa. Lung sounds clear bilaterally. Nasal flaring present. Fontanel level and soft with large ecchymotic caput succedaneum noted, Blood-tinged mucus noted at the vaginal opening. Has voided and stooled one time since birth. Uric acid crystals observed in the urine. Breastfed x 1 in the past 6 hr for 10 min.

Axillary temperature 36.1° C (97° F)

Respiratory rate 78/min

Yellow discoloration noted of sclera and oral mucosa

Nasal flaring present

Has voided and stooled one time since birth

Lung sounds clear bilaterally

Breastfed x 1 in the past 6 hr for 10 min

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","G"]

Answer:

Axillary temperature 36.1° C (97° F)
Respiratory rate 78/min
Yellow discoloration noted of sclera and oral mucosa
Nasal flaring present
Has voided and stooled one time since birth
Breastfed x 1 in the past 6 hr for 10 min

Rationale:

Axillary temperature 36.1° C (97° F): This is below the normal newborn range (36.5–37.5° C). Hypothermia can lead to complications like hypoglycemia and respiratory distress, requiring immediate attention.
Respiratory rate 78/min: A normal newborn respiratory rate is 30–60/min. A rate above 60 suggests tachypnea, which can indicate respiratory distress or underlying pathology.
Yellow discoloration noted of sclera and oral mucosa: Jaundice appearing before 24 hours or worsening after 36 hours may indicate pathologic jaundice, such as from hemolysis, trauma (e.g., caput succedaneum), or sepsis.
Nasal flaring present: This is a sign of increased respiratory effort and may signal respiratory compromise requiring prompt evaluation.
Has voided and stooled one time since birth: A healthy newborn should void and pass stool multiple times by 36 hours. This finding raises concerns for dehydration or feeding issues.
Breastfed x 1 in the past 6 hr for 10 min: Inadequate feeding can contribute to poor intake, weight loss, dehydration, and worsening jaundice. Feeding frequency should be every 2–3 hours in the early days.

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Correct Answer is C

Explanation

A. 22/min: A respiratory rate of 22 breaths per minute is well below the normal range for a newborn. This could indicate respiratory depression or central nervous system suppression, both of which are concerning in a neonate and require immediate evaluation.

B. 110/min:. A respiratory rate of 110/min suggests tachypnea, which may be due to transient tachypnea, respiratory distress, or sepsis and warrants further assessment.

C. 48/min: The normal respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 48/min falls comfortably within this expected range, indicating adequate respiratory function. Breathing should also be assessed for regularity, absence of grunting, and use of accessory muscles.

D. 100/min: This respiratory rate is much too high for a newborn and indicates marked tachypnea, which could be associated with respiratory compromise such as hyaline membrane disease, meconium aspiration, or pneumonia. Immediate evaluation would be needed in such cases.

A. Hypomagnesemia B. Hypocalcemia C. Hypoglycemia D. Hyperbilirubinemia

Correct Answer is C

Explanation

A. Hypomagnesemia: Infants born to diabetic mothers can experience low magnesium levels, typically due to maternal urinary losses or poor placental transfer. However, symptoms are usually mild and less immediate compared to hypoglycemia, making it a secondary concern rather than a priority in the acute setting.

B. Hypocalcemia: This is another possible complication in neonates of diabetic mothers, often presenting within the first few days of life. Though it can cause tremors or seizures, it generally develops after hypoglycemia and is less immediately life-threatening, making it important but not the initial priority.

C. Hypoglycemia: Hypoglycemia is the most urgent and common complication in macrosomic newborns of diabetic mothers. After birth, the sudden discontinuation of maternal glucose supply combined with persistent fetal hyperinsulinemia can lead to rapid and severe drops in blood glucose levels. If untreated, it can cause neurologic injury, seizures, or death, making it the top priority for immediate assessment and management.

D. Hyperbilirubinemia: This condition may occur in macrosomic infants due to increased red blood cell turnover, but it tends to develop over the first few days postpartum. While still important, it is not an immediate threat to the newborn’s life in the first hours of life like hypoglycemia is.

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Correct Answer is C

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Correct Answer is C

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