The nurse is performing an assessment on a neonate shortly after delivery. The nurse is most concerned about which assessment finding?

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Eyelids should sit above the pupils symmetrically with irises showing. Ptosis (drooping of the eyelid below the level of the pupil) could indicate paralysis of the oculomotor nerve. This finding warrants further investigation. At the time of birth, there should be no cranial nerve abnormalities. (Option A) Crackles (rales) indicate fluid in the lungs and are expected immediately after birth. Rales will clear as the neonate transitions to extrauterine life. However, wheezes, stridor, or persistence of crackles after the first few hours of birth are abnormal and should be reported. (Option B) Percussing dullness in the hypogastric area is a normal finding when the bladder is full. The neonate should void spontaneously within a few hours after birth. (Option D) An undescended testicle (cryptorchidism) at birth is not concerning. Most undescended testes descend spontaneously by age 6 months. Educational objective: At the time of birth, there should be no cranial nerve abnormalities. Rales (crackles) indicate fluid in the lungs and will clear as the neonate transitions to extrauterine life. Most undescended testes descend spontaneously by age 6 months.

The Nurse Is Performing an Assessment on a Neonate Shortly