A nurse is caring for a newborn in the newborn nursery unit. Exhibits After reviewing the information in the newborn's electronic medical record (EMR), which of the following findings should the nurse report to the provider? Click to highlight below the findings that the nurse should report to the provider. To deselect a finding, click on the finding again. Body system Findings Neurologic Irritability Pupil response Integumentary Milia on nose and cheeks Lanugo on bilateral shoulders Cardiopulmonary Axillary temperature Respiratory rate Apical heart rate Lung findings Gastrointestinal Stool characteristics Abdomen findings

Body System Finding Interpretation Report to Provider? Neurologic Irritability Can be normal if mild, but persistent irritability may indicate hypoglycemia, hypocalcemia, withdrawal, or infection → concerning ✅ Yes Pupil response (brisk, equal) Normal neuro finding ❌ No Integumentary Milia on nose/cheeks Benign, normal newborn finding ❌ No Lanugo on shoulders Normal in preterm/term newborns ❌ No Cardiopulmonary Axillary temperature 36.2°C (97.2°F) Low temp (normal 36.5–37.5°C). Hypothermia can indicate infection, poor thermoregulation ✅ Yes Respiratory rate 80/min Tachypnea (normal 30–60/min). May indicate respiratory distress, sepsis, metabolic issue ✅ Yes Apical heart rate 158/min Normal (110–160/min) ❌ No Lung findings (clear) Normal ❌ No Gastrointestinal Stool characteristics (meconium, normal) Normal ❌ No Abdomen findings (not abnormal) Normal ❌ No 🧾 Explanation Irritability: While some fussiness is expected, persistent irritability is a red flag for metabolic or infectious causes. Temperature 36.2°C: Below normal → newborn hypothermia, which can worsen quickly. Respiratory rate 80/min: Markedly elevated → tachypnea, possible respiratory distress or sepsis. Other findings (milia, lanugo, brisk pupils, HR 158, clear lungs, normal stool) are expected newborn variations and do not require reporting. ✅ Final Answer: The nurse should report: Neurologic: Irritability Cardiopulmonary: Axillary temperature 36.2°C Cardiopulmonary: Respiratory rate 80/min