The nurse is performing the initial assessment of a newborn. Which of the following findings should the nurse report to the health care provider? Select all that apply.

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Nurses caring for newborns must be able to distinguish between normal physiologic variations and unexpected findings that require further intervention. Unexpected findings in newborns include: Decreased muscle tone (ie, hypotonia), which may indicate a congenital neurological abnormality (eg, Down syndrome) or spinal injury (Option B). Newborns normally have increased muscle tone and should resist movement of the extremities. Sacral dimples, with or without tufts of hair or skin tags, are associated with spina bifida occulta, which is an incomplete closure of vertebrae that cannot be seen externally (Option D). Presence of a single umbilical artery, which is sometimes associated with congenital defects, particularly of the kidneys and heart (Option E). Normal umbilical cords contain 2 arteries and 1 vein. (Option A) Bluish discoloration of the hands, feet, and around the mouth (ie, acrocyanosis) is a common, harmless finding during the first 24 hours after birth and through the first week of life when exposed to cold. (Option C) The normal heart rate for a newborn is 110-160/min when awake and calm. However, the heart rate may further range from 80/min during rest to 180/min when crying or agitated. Educational objective: Nurses assessing newborn clients should monitor closely for abnormal findings that may require further intervention. Some abnormal findings in a newborn include decreased muscle tone, sacral dimple, and a single artery in the umbilical cord. Bluish discoloration of the hands, feet, and lips and heart rate of 110-160/min are normal physiologic variations in newborns.

The Nurse Is Performing the Initial Assessment of a Newborn