Question

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?

A. Substernal retractions
B. Acrocyanosis
C. Overlapping suture lines
D. Head circumference 33 cm (13 in)

Answer 1

The nurse should report the finding of substernal retractions to the provider, as it may indicate a potential breathing problem or lung issue. Acrocyanosis is a common finding in newborns and usually resolves on its own. Overlapping suture lines and a head circumference of 33 cm are within the expected range for a newborn and do not require immediate medical attention.

Step-by-step explanation:

The nurse should report the finding of substernal retractions to the provider. Substernal retractions are a sign of respiratory distress in newborns and may indicate a potential breathing problem or lung issue. The nurse should notify the provider so appropriate interventions can be taken to ensure the newborn's well-being.

Acrocyanosis, which is cyanosis or bluish discoloration of the extremities, is a common finding in newborns and usually resolves on its own within a few hours or days. It is not considered a cause for immediate concern.

Overlapping suture lines, where the bones of the skull meet, can also be a normal finding in newborns and does not typically require medical intervention.

A head circumference of 33 cm (13 in) is within the expected range for a newborn. The nurse should continue to monitor the head circumference as part of the newborn's growth assessment.