A nurse assesses a newborn at 1 hour of life. Which finding requires immediate reporting to the provider?
- A.Respiratory rate of 48 breaths per minute
- B.Skin with acrocyanosis of the hands and feet
- C.Apical pulse of 148 beats per minute
- D.Grunting on expiration and nasal flaring
Show answer & rationale
Correct answer
D. Grunting on expiration and nasal flaring
Rationale
D is correct: Expiratory grunting and nasal flaring are signs of respiratory distress in the newborn, indicating the infant is working hard to keep alveoli open. These findings require immediate provider notification and intervention. A is incorrect: A respiratory rate of 30-60 breaths per minute is normal for a newborn; 48 is within the expected range. B is incorrect: Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in the first 24-48 hours of life as peripheral circulation adjusts. Central cyanosis (lips, tongue) would be abnormal. C is incorrect: A normal newborn heart rate ranges from 110-160 bpm; 148 is within normal limits.
Key concepts