48. A nurse performs an assessment on a newborn, 39 weeks' gestation, with Apgar scores of 8 and 9. Which findings are not "normal" in a newborn of this gestational age?
Select all that apply.
48. A nurse performs an assessment on a newborn, 39 weeks' gestation, with Apgar scores of 8 and 9. Which findings are not "normal" in a newborn of this gestational age?
Select all that apply.
. A slight heart murmur heard at 6 hours of age.
. Overlapping skull bones.
. Bluish hue of fingers and toes.
. Slightly incurving pinnae.
. Expiratory grunting with respirations.
Test-Taking Tip
Each of the alternatives should be viewed separately, as normal or not normal. Eliminate the normal findings (Answers 2, 3, and 4).
Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Health Screening
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Answer 1 is correct because a murmur heard after 4 hours can be indicative of a cardiac condition and needs further investigation. Answer 2 is incorrect because overlapping skull bones, called molding, are a normal finding in the term infant. Answer 3 is incorrect because the bluish hue of fingers and toes, called acrocyanosis, is a normal part of the infant's transition from intrauterine to extrauterine life. Answer 4 is incorrect because the pinnae of the ears are normally incurving at term. Answer 5 is correct because grunting with respirations is not a normal finding at 39 weeks' gestation and can be indicative of respiratory distress.