The nurse completes an initial newborn examination. The nurse's findings include the following: heart rate, 136 beats/minute; respiratory rate, 64 breaths/minute; temperature, 98.2 °F (36.8 °C). 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?
A. Absent bowel sounds
B. Heart murmur
C. Respiratory rate
D. Temperature
ANS: A
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. The other findings are normal (it is not uncommon to hear murmurs in infants less than 24 hours old).
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