The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?
1. Mean blood pressure 55 mmHg
2. Pulse rate 145, systolic murmur heard
3. Pauses in respiration lasting 30 seconds
4. Respiratory rate 60, crackles present bilaterally
3
Explanation:
1. This is a normal finding in an infant at 1 hour of life.
2. This pulse rate is normal. Systolic murmurs are very unlikely to indicate serious pathology and are usually caused by incomplete closure of the ductus arteriosus or foramen ovale.
3. Pauses in respirations greater than 20 seconds are considered episodes of apnea and require further intervention.
4. This respiratory rate is normal; crackles are commonly heard in the first few hours after birth as the infant reabsorbs the fluid in the lungs that was present at birth.
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