A practical nurse is observing a full-term newborn who is 8 hours old. Which of the following physical findings should the nurse recognize as expected and document as normal? Select all that apply.
- The newborn's hands and feet appear bluish while the trunk remains pink.Answer
- BThe newborn displays visible intercostal retractions when taking a breath.
- The newborn startles and symmetrically extends the arms when a loud noise occurs.Answer
- DThe newborn has a sustained apical heart rate of 92 beats per minute while awake.
- The newborn's toes fan outward when the outer edge of the sole is stroked.Answer
- FThe newborn exhibits a weak, high-pitched cry when disturbed.
Answer
The expected normal findings for an 8-hour-old newborn are bluish hands and feet with a pink trunk (acrocyanosis), symmetrical extension of the arms to a loud noise (Moro reflex), and outward fanning of the toes when the sole is stroked (Babinski reflex).
Expected physical findings for a newborn in the first 24 hours of life include acrocyanosis (bluish hands and feet with a pink trunk) due to sluggish peripheral circulation. Additionally, normal primitive neurological reflexes should be present, including the Moro (startle) reflex characterized by symmetrical extension of the arms, and a positive Babinski reflex where the toes fan outward when the sole of the foot is stroked.
Step-by-Step Solution
Key Concept
Expected physiological and neurological findings in a full-term newborn during the first 24 hours of life.