The nurse completes an initial newborn examination. The nurses findings include the following: heart rate 136 beats/minute; respiratory rate 64 breaths/minute; temperature 98.2F (36.8C). The nurse also documents a heart murmur,absence of bowel sounds symmetry of ears and eyes no grunting or nasal flaring and full range of movement of all extremities. Which finding requires immediate consultation with the health-care provider?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: B

Rationale: The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection. Then the nurse can take the baby and suction the babys mouth and then the nares if needed. Auscultating the babys heart and lungs will occur later. The parents may not name the baby immediately but even if they have recording the name would not take priority over using standard precautions to prevent the spread of disease.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: The babys 5-minute Apgar score is 8 (motion 2; pulse 2; grimace 2; appearance 1; respirations 1). If a 5-minute Apgar score is less than 9 the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this babys problems are related to either oxygenation or perfusion the nurse should assess the oximetry reading and administer oxygen if needed.

Correct Answer: b

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.