The nurse performing an initial newborn assessment observes a bluish discoloration of the hands and feet. The trunk has a pink color. Which action by the nurse is appropriate?

Question

The nurse performing an initial newborn assessment observes a bluish discoloration of the hands and feet.  The trunk has a pink color.  Which action by the nurse is appropriate?

Quizplus · Accepted Answer

Acrocyanosis or peripheral cyanosis of the hands and feet is a benign finding during a newborn's transition to extrauterine life. It is especially common during the first 24 hours of life or in the first week if the newborn is cold. Manifestations include a bluish discoloration of the hands and feet and sometimes the skin around the mouth. Acrocyanosis results from poor perfusion to the periphery of the body, an initial mechanism to reduce heat loss and stabilize temperature. Initial nursing management includes promoting thermoregulation by placing the newborn skin-to-skin with the mother or under a radiant warmer and assessing axillary temperature (Option D). (Option A) Acrocyanosis is considered normal during the first day of life. Therefore, supplemental oxygen is not warranted unless central cyanosis or other signs of respiratory distress (eg, tachypnea) occur. (Option B) Transient acrocyanosis without central cyanosis in the first day of life is considered normal and not indicative of a pathologic condition (eg, murmur). (Option C) Because peripheral cyanosis is a normal finding associated with the newborn's inability to retain heat adequately, the best action is to facilitate newborn thermoregulation and continue routine observation for any respiratory abnormalities. Educational objective: Acrocyanosis manifests as a bluish discoloration of the newborn's hands and feet; it is considered a normal finding during the first day of life or if the newborn becomes cold. The best nursing action is to promote warmth by placing the newborn skin-to-skin with the mother.

The Nurse Performing an Initial Newborn Assessment Observes a Bluish