Health Promotion and Maintenance
72. A client delivered an 8-pound, 9-ounce neonate at 39 weeks' gestation. Which observations, if found during the initial assessment, are normal findings and do not need to be reported to a physician? Select all that apply.
. Heart rate of 170 at rest.
. Respiratory rate of 46.
. Circumoral cyanosis.
. Caput succedaneum over the occiput.
. Mongolian spots.
Test-Taking Tip
Note the key word in the stem—normal—and eliminate the two answers that pertain to abnormal findings.
Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
. . .
Answer 1 is incorrect because the normal heart rate at rest is 110 to 160. A rate of 170 is tachycardia, which is not normal after birth, and may indicate neonatal sepsis. This needs to be reported to the physician. Answer 2 is correct because the normal respiratory rate is 30 to 60 breaths/min. This finding does not require any intervention and does not need to be reported to the physician. Answer 3 is incorrect because circumoral cyanosis, a bluish color around the mouth, is an abnormal finding and requires further assessment, including pulse oximetry. Findings need to be reported to the physician. Answer 4 is correct because caput succedaneum is edema over the back of the fetal head caused by pressure over the presenting part of the fetal head and it resolves spontaneously. This finding does not require any intervention and does not need to be reported to the physician. Answer 5 is correct because mongolian spots are a normal finding in dark-skinned neonates. This finding does not require any intervention and does not need to be reported to the physician.