The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. The nurse is most concerned about:
1. Neonatal jaundice.
2. Polycythemia.
3. Neonatal hyperthermia.
4. Respiratory distress.
4
Rationale 1: A high bilirubin level would be an indication of jaundice.
Rationale 2: An excess of red blood cells would be noted with polycythemia.
Rationale 3: A high temperature would indicate hyperthermia.
Rationale 4: Nasal flaring, facial grimacing, and excessive mucus are signs of respiratory distress.
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