A nurse is caring for a newborn immediately following birth. Exhibits Click to highlight the newborn's assessment findings that require follow-up by the nurse. To deselect a newborn's assessment finding, click on the newborn's assessment finding again. A nurse is caring for a newborn immediately following birth. Nurses' Notes 2100: Newborn has strong, steady cry. Skin tone consistent with genetic background. Acrocyanosis noted on bilateral extremities and hands. Respirations are even and unlabored. Lung fields clear. Brachial pulse regular. Apical heart rate regular. Moves all extremities actively. 2200: Newborn has occasional strong cries. Skin tone consistent with genetic background. Acrocyanosis noted on bilateral extremities and hands. Lanugo noted on the posterior back. Respirations are even and unlabored. Sternal retractions noted. Lung fields with coarse rhonchi noted in bilateral lung fields. Brachial pulse regular. Apical heart rate regular. Moves all extremities actively Vital signs 2100: Temperature 36.5° C (97.7° F) Axillary Heart rate 152/min Respiratory rate 54/min 2200: Temperature 35.7° C (96.3° F) Axillary Heart rate 140/min Respiratory rate 68/min

The newborn's assessment findings that require follow-up: Temperature 35.7°C (96.3°F) at 2200: Hypothermia in newborns can lead to cold stress, which increases the risk of respiratory distress and hypoglycemia. The newborn’s temperature should be closely monitored, and warming measures should be initiated to prevent further complications. Respiratory rate 68/min at 2200: A respiratory rate above 60 breaths per minute in a newborn is considered tachypnea and can indicate respiratory distress or underlying conditions such as infection. The newborn should be further evaluated to determine the cause of the tachypnea and to ensure proper oxygenation. Sternal retractions at 2200: Sternal retractions suggest that the newborn is experiencing increased work of breathing, which is a key sign of respiratory distress. This requires immediate evaluation to assess the severity and identify potential causes, such as respiratory infections or inadequate ventilation. Coarse rhonchi in bilateral lung fields at 2200: The presence of coarse rhonchi indicates abnormal breath sounds, often related to fluid retention or infection in the lungs. This finding requires further assessment and possibly interventions to clear the airway and support respiratory function.