The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse would expect to find:
A. An apical pulse of 100
B. An absence of tonus
C. Cyanosis of the feet and hands
D. Jaundice of the skin and sclera
Correct Answer: C. Cyanosis of the feet and hands
Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. Acrocyanosis is bluish discoloration around the mouth and extremities, with the remaining area pink. It is a benign finding often seen in healthy newborns and is common in the initial days of life due to initial peripheral vasoconstriction. This is managed by routine newborn care. The routine newborn care management which involves pulse oximetry and screening of congenital heart disease (CHD).
Option A: An apical pulse should be 120–160. The next step would be cardiac auscultation, making a note of the rate, rhythm, and quality of sounds. Heart sounds should have a single first heart sound and second split heart sound. Neonatal murmurs on the first day of life are common and are usually transient.
Option B: The baby should have muscle tone, making answer B incorrect. A neurological exam should include a more thorough assessment of tone & level of alertness than the initial inspection. Tone can be assessed by holding up the newborn under the bilateral axilla.
Option D: Jaundice immediately after birth is pathological jaundice and is abnormal. Pathologic jaundice may occur in the first 24 hours of life and is characterized by a rapid rate of rising in the bilirubin level more than 0.2 mg/dl per hour or 5 mg/dl per day.