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A nurse in an emergency department is performing a physical assessment on a 2-week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?

a) The presence of milia on the baby's nose
b) Jaundice that started on the second day of life
c) An irregular-shaped birthmark on the back
d) Respiratory rate of 60 breaths per minute

1 Answer

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Final answer:

The nurse's priority is to report the newborn's respiratory rate of 60 breaths per minute to the provider, as it is the upper limit of normal. This is crucial as per the Apgar score criteria, and may indicate the need for further examination or medical assistance.

Step-by-step explanation:

When performing a physical assessment on a 2-week-old male newborn, the priority for the nurse to report to the provider is d) Respiratory rate of 60 breaths per minute. A newborn's normal respiratory rate should be between 30-60 breaths per minute, but a consistent rate at the upper limit of normal or evidence of respiratory distress may be concerning. It's especially important when considering the Apgar score criteria, which includes respiration as a critical measurement. The other options, such as milia, a birthmark, or jaundice that began on the second day of life (which can be normal), are generally not as urgent unless accompanied by other symptomatic concerns.

Just after birth, a newborn undergoes an Apgar test assessing five criteria, including respiration and heart rate. An Apgar score lower than 7 at the 5-minute mark or below 5 at any time may indicate that the baby is in distress and requires medical assistance. Therefore, a high respiratory rate at two weeks old could be a sign of underlying issues and warrants further examination and potentially immediate medical attention.

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