The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma
The nurse's findings include the following parameters: heart rate, 136 beats per minute; respiratory rate, 64 breaths per minute; temperature, 98.2°F (36.8°C); length, 49.5 cm; and weight, 3500 g. The nurse documents the presence of 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 assessment would warrant further investigation and require immediate consultation with the baby's health-care provider?
a. Respiratory rate
b. Presence of a heart murmur
c. Absent bowel sounds
d. Weight
ANS: c
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a. The respiratory rate and weight are normal findings. It is not uncommon to hear murmurs in infants less than 24 hours old.
b. It is not uncommon to hear murmurs in infants less than 24 hours old.
c. Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small, distinct section of the intestines; therefore, this finding should be reported.
d. The weight is within normal limits.
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