A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?
A newborn who is 12 hours post-delivery and has a temperature of 37.0°C (98.6°F).
A newborn who is 27 hours post-delivery and has not voided.
A newborn who is 18 hours post-delivery and has not passed meconium.
A newborn who is 18 hours post-delivery and has acrocyanosis.
The Correct Answer is B
Choice A rationale
A newborn with a temperature of 37.0°C (98.6°F) is within the normal range for newborns and does not require immediate intervention.
Choice B rationale
A newborn who has not voided within 27 hours post-delivery requires immediate intervention. Newborns should void within the first 24 hours of life. Failure to void may indicate dehydration, urinary tract obstruction, or renal issues.
Choice C rationale
A newborn who has not passed meconium within 18 hours post-delivery is concerning but not as urgent as not voiding. Newborns typically pass meconium within the first 24-48 hours.
Choice D rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves on its own. It does not require immediate intervention.
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Correct Answer is D
Explanation
Choice A rationale
Stretching arms out and then back in is a common reflex in newborns known as the Moro reflex. It is not a sign of feeding readiness but rather a response to a sudden loss of support or a loud noise.
Choice B rationale
Turning the head toward a parent’s voice is a sign of auditory recognition and bonding, not necessarily feeding readiness. It indicates the infant’s ability to recognize familiar sounds.
Choice C rationale
Grasping a parent’s finger when placed in the infant’s palm is a primitive reflex known as the palmar grasp reflex. It is not related to feeding readiness but is a normal reflexive action in newborns.
Choice D rationale
Bringing their hand to their mouth is a sign of feeding readiness. This action indicates that the infant is hungry and ready to feed. It is an early cue that the baby is ready to eat.
Correct Answer is D
Explanation
Choice A rationale
A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
Choice B rationale
A respiratory rate of 100/min is also too high for a newborn and may indicate respiratory distress.
Choice C rationale
A respiratory rate of 24/min is too low for a newborn and may indicate respiratory depression.
Choice D rationale
The normal respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 60/min is within this range.