A nurse is assessing a newborn that was just born. Which newborn finding will cause the nurse to intervene immediately?
a. Molding
b. A lack of reflexes
c. Cyanotic hands and feet
d. A soft, protuberant abdomen
ANS: B
A lack of reflexes must be addressed quickly. Assessment of these reflexes is vital because the newborn depends largely on reflexes for survival and in response to its environment. Molding, or overlapping of the soft skull bones, allows the fetal head to adjust to various diameters of the maternal pelvis and is a common occurrence with vaginal births. Normal physical characteristics include the continued presence of lanugo on the skin of the back; cyanosis of the hands and feet for the first 24 hours; and a soft, protuberant abdomen.
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