Question

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (Select all that apply.)

a) Increased heart rate and respiratory rate.
b) Decreased muscle tone.
c) Presence of a strong Moro reflex.
d) Cyanosis of the hands and feet.

Answer 1

Upon a physical assessment of a newborn, a nurse should expect indications of increased heart rate and respiratory rate, strong Moro reflex, and possibly cyanosis of the hands and feet (acrocyanosis), which are normal findings. Decreased muscle tone may be concerning and should be assessed critically as part of the Apgar score, which evaluates the newborn's overall health.

Step-by-step explanation:

During a physical assessment of a newborn upon admission to the nursery, the nurse should expect to see certain manifestations that are typical for newborns. These include:

• Increased heart rate and respiratory rate: A newborn's heart rate should be fairly high, typically over 100 beats per minute, and plenty of breaths per minute, as they adjust to breathing outside the womb. This meets the 'pulse' and 'respiration' criteria of the Apgar score.
• Presence of a strong Moro reflex: This is the 'grimace' aspect of the Apgar score, reflecting the newborn's reflexes.
• Cyanosis of the hands and feet: While full-body cyanosis would be a cause for concern, the presence of a bluish color in the extremities, known as acrocyanosis, is common during the first hours of life. This links to the 'appearance' part of the Apgar score.

Decreased muscle tone may be concerning unless it's very mild, as the 'activity' aspect of the Apgar score looks for good muscle tone. The Apgar score is an assessment of a newborn's health, using five criteria: skin color, heart rate, reflex, muscle tone, and respiration, where a score of 8 or above indicates normal function.