Difficulty: Medium
Average Score: 75%
Simulated
The nurse is performing an assessment on a newborn. Which findings require follow-up? Select all that apply.
Correct answer
A, C
Rationale
A high-pitched cry (A) may indicate neurological issues or discomfort, requiring further investigation. White patches on cheeks or tongue (C) suggest oral thrush (Candida infection), which needs medical attention. A heart rate of 175/minute while crying (B) is within normal limits for a newborn under stress (normal range: 120-180 bpm). Vernix caseosa in the creases (D) is a normal finding, as it is a protective coating often present at birth. A respiratory rate of 25/minute (E) is below the normal range (30-60 breaths/minute at rest), but without other symptoms, it may not immediately require follow-up unless persistent.