The nurse is assessing a newborn at 1 hour of age. Which finding requires the nurse's immediate action?

A) Pauses in respiration lasting 30 seconds:
Pauses lasting longer than 20 seconds or accompanied by other signs of distress would warrant further evaluation. A 30-second pause by itself, without additional concerning symptoms, is generally not a reason for immediate action.

B) Respiratory rate 36, crackles present bilaterally:
The presence of bilateral crackles is concerning. Crackles can indicate fluid in the lungs, possibly from retained amniotic fluid or respiratory distress syndrome (RDS). In a term newborn, bilateral crackles at this time, especially if accompanied by tachypnea or other signs of respiratory distress, may indicate a serious respiratory issue, such as aspiration pneumonia or RDS. Immediate assessment and intervention are necessary to ensure the infant is breathing adequately and that there are no underlying complications.

C) Apical heart rate of 160 with mild systolic murmur heard:
An apical heart rate of 160 is within the normal range for a newborn (typically 120-160 bpm). A mild systolic murmur is also not uncommon in newborns and may be benign, especially in the first few days of life. Murmurs are often transient and can be caused by normal circulatory changes as the newborn's cardiovascular system adjusts after birth. Although a heart murmur should be monitored, it is not typically an urgent concern unless associated with signs of poor perfusion or other cardiac symptoms.

D) Small white papules on nose and chin:
These small white papules are likely milia, which are common and harmless in newborns. Milia are keratin-filled cysts that typically appear on the face, especially around the nose and chin. They are a normal finding and resolve on their own without treatment. These papules do not require immediate action.

A) The neonate with respirations of 78 and a heart rate of 176:
This is the most concerning finding and requires immediate evaluation. Normal respiratory rate for a newborn is typically between 30 and 60 breaths per minute, so a rate of 78 breaths per minute is significantly elevated, indicating potential respiratory distress. Additionally, a heart rate of 176 beats per minute, while somewhat elevated, could indicate tachycardia, especially if the baby is experiencing distress or inadequate oxygenation. This combination of abnormal vital signs may point to respiratory or cardiovascular compromise, such as respiratory distress syndrome or other neonatal respiratory issues, which requires immediate evaluation and intervention.

B) The neonate with a temperature of 99.1°F and a weight of 3000 grams:
This neonate’s temperature is within the normal range (97.7°F to 99.5°F), and a weight of 3000 grams is also considered appropriate for a full-term newborn. These findings do not raise any immediate concerns, and no further action is necessary based on these observations alone.

C) The neonate with raised white specks on the gums:
Raised white specks or nodules on the gums are often a normal finding in newborns and are called Epstein pearls. These are benign cystic formations that do not require treatment. They are not a cause for concern and are common in newborns, usually disappearing on their own within a few weeks.

D) The neonate with white spots on the bridge of the nose:
White spots on the nose are likely to be Milia, which are small, benign cysts commonly seen on the face of newborns, particularly on the nose, cheeks, and chin. Milia are harmless and typically resolve without treatment within a few weeks. There is no need for concern in this case.