Sarah works in the labor and delivery unit as a transition nurse. Her department has instituted a new bedside transition period where newborns make the transition to extrauterine life in their mother’s

Sarah works in the labor and delivery unit as a transition nurse. Her department has instituted a new bedside transition period where newborns make the transition to extrauterine life in their mother’s recovery room about an hour after birth. Sarah’s next assignment is a new baby boy with Apgar scores of 8 and 9, born by cesarean about 1 hour ago to Lindsay, a 28-year-old G1. Sarah’s assessment findings of the new baby boy are:

• Vital signs: axillary temperature 37.0° C, heart rate 145, respiratory rate 75
• Observations: color pink, respirations rapid and unlabored, good muscle tone, good arm and leg movement
• Auscultation: breath sounds clear and equal bilaterally, strong heart sounds with a soft murmur, active bowel sounds in all four quadrants
• Physical assessment: fontanels soft and flat, eyes clear with red reflex in both, ears normal shape and placement, soft and hard palate intact, strong suck, both nares patent, capillary refill less than 2 seconds, both testes descended
• Measurements: weight 8 lb 6 oz, length 20 in, head circumference 36.2 cm, chest circumference 36.0 cm

As Sarah is charting her findings, Lindsay asks Sarah if everything is OK with her baby. (Learning Objectives 1, 2, 3, and 4)

A.   Which assessment findings for this newborn are abnormal? What is the most likely cause of these abnormal findings?

B.   How would Sarah explain these abnormal findings to Lindsay?

C.   What are the nursing interventions that Sarah would implement based on these findings?

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