The practical nurse (PN) receives shift report for four newborns in the full-term newborn nursery.
Which infant should the PN assess first?
A.
The ten-hour-old with circumoral cyanosis.
B.
The one-day-old with a positive Babinski’s reflex
C.
The two-day old with negative Ortolani’s sign
D.
The six-hour-old with a large sacral “stork bite”
The correct answer and Explanation is :
The correct answer is A. The ten-hour-old with circumoral cyanosis.
Explanation:
Circumoral cyanosis refers to a bluish discoloration around the mouth and is a concerning sign in newborns. It can indicate a lack of oxygen in the blood, which may suggest underlying respiratory distress or cardiac issues. Newborns are particularly vulnerable to conditions that can lead to inadequate oxygenation, such as congenital heart defects or respiratory distress syndrome.
In contrast, the other options describe findings that are generally considered normal or benign in newborns:
- B. The one-day-old with a positive Babinski’s reflex: This is a normal reflex in newborns, indicating proper neurological function. The Babinski reflex is expected in infants up to about 12 months of age.
- C. The two-day-old with a negative Ortolani’s sign: A negative Ortolani’s sign indicates that the hip joint is stable and suggests that there are no signs of developmental dysplasia of the hip, which is a reassuring finding.
- D. The six-hour-old with a large sacral “stork bite”: Stork bites, or nevus simplex, are common vascular lesions that usually fade over time. They are not indicative of a health issue and are often seen in newborns.
In a clinical setting, when prioritizing assessments, the focus should be on signs that indicate potential life-threatening conditions. Circumoral cyanosis is an immediate red flag that requires prompt evaluation to determine the cause and initiate necessary interventions, making it the priority for the practical nurse.