Question

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

a. Pink skin
b. Strong cry
c. Respiratory rate of 60 breaths per minute
d. Presence of Moro reflex

Answer 1

The nurse should report the clinical finding of a respiratory rate of 60 breaths per minute to the provider, as it might indicate an issue, even though it can be within the normal range for newborns depending on the context. Pink skin, strong cry, and presence of Moro reflex are generally considered normal findings in a full-term newborn.

Step-by-step explanation:

When assessing a full-term newborn, the clinical finding that should be reported to the provider is c. Respiratory rate of 60 breaths per minute. According to the Apgar score, which assesses five criteria: skin color, heart rate, reflex, muscle tone, and respiration, the expected normal respiratory rate should range from 30 to 60 breaths per minute. However, a rate at the high end of this range can be normal if the baby is crying or agitated. If the respiratory rate is consistently high when the baby is calm, it could indicate respiratory distress or another issue that requires medical attention.

Pink skin, strong cry, and presence of the Moro reflex are generally considered normal findings and are part of the expected physiological responses in a healthy newborn. A baby with pink skin is showing good oxygenation, a strong cry is a sign of healthy lungs and airway, and the Moro reflex is an important neurological response that should be present at birth and for the first few months of life.