The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?
1. Respiratory rate 60, crackles present bilaterally
2. Pulse rate 145, systolic murmur heard
3. Mean blood pressure 55 mm Hg
4. Pauses in respiration lasting 30 seconds
Correct Answer: 4
Rationale 1: 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 present at birth.
Rationale 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.
Rationale 3: This is a normal finding in an infant at 1 hour of life.
Rationale 4: Pauses in respirations greater than 20 seconds are considered episodes of apnea and require further intervention.
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