A nurse is caring for a newborn 8 hours of age
Nurses Notes
Newborn is alert and active. Oral mucosa pink. Respirations easy and unlabored. Extremities flexed. Good muscle tone. Breastfed vigorously x 2 for 30 to 40 min. Fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. No stool or void noted since birth
36 hours of age:
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 urine. Breastfed x 1 in the past 6 hr for 10 min.
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 mucosal 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
The Correct answer and Explanation is:
Correct Answer:
The following assessment findings require follow-up by the nurse:
- Axillary temperature 36.1°C (97°F)
- Respiratory rate 78/min
- Yellow discoloration noted of sclera and oral mucosa
- Nasal flaring present
- Breastfed x 1 in the past 6 hr for 10 min
Explanation:
In this scenario, the nurse is caring for a newborn at 36 hours of age, and there are several findings that require follow-up:
- Axillary Temperature 36.1°C (97°F): A newborn’s normal body temperature typically ranges between 36.5°C and 37.5°C (97.7°F and 99.5°F). An axillary temperature of 36.1°C (97°F) is below this range and indicates hypothermia. Hypothermia in newborns can lead to cold stress, which increases the risk of hypoglycemia, respiratory distress, and metabolic acidosis. The nurse should take measures to warm the newborn and monitor the temperature closely.
- Respiratory Rate 78/min: The normal respiratory rate for a newborn is between 30 and 60 breaths per minute. A respiratory rate of 78/min is significantly elevated and may indicate respiratory distress. The presence of nasal flaring further supports this concern, as it is a sign of increased work of breathing. The nurse should assess for other signs of respiratory distress, such as grunting, retractions, or cyanosis, and intervene as needed.
- Yellow Discoloration of Sclera and Oral Mucosa: Yellow discoloration of the sclera and oral mucosa is indicative of jaundice, which can be physiological or pathological in newborns. Jaundice occurring within the first 24 hours of life or becoming noticeable by 36 hours may be concerning and could indicate conditions like hemolytic disease or infection. The nurse should assess the bilirubin levels and monitor the progression of jaundice.
- Nasal Flaring Present: Nasal flaring is a sign of respiratory distress in newborns. It occurs as the infant attempts to increase oxygen intake due to difficulties in breathing. This finding, in conjunction with the elevated respiratory rate, warrants further assessment and potential intervention to ensure adequate oxygenation.
- Breastfed x 1 in the past 6 hr for 10 min: The newborn’s feeding pattern is inadequate. Newborns should breastfeed every 2 to 3 hours, and sessions typically last 20 to 30 minutes. Insufficient breastfeeding can lead to dehydration, hypoglycemia, and inadequate nutrition. Additionally, uric acid crystals in the urine (orange-colored crystals) are often a sign of dehydration in newborns, further indicating that the infant may not be receiving adequate breast milk.
In summary, the nurse should follow up on these findings with appropriate interventions such as warming the infant, addressing respiratory distress, evaluating jaundice, ensuring adequate breastfeeding, and potentially escalating care if needed.