The nurse is conducting a routine assessment of a 24. hour-old infant who was delivered vaginally.At h Lounces, heart rate was 160 beats/minute, respiratory rate was so breaths/minute, and the equires further assessment? A Respiratory rate of 59 breaths/minute. B 2 em bluish purple area on the sacrum C Edema present along the sagitial suture. D Weight loss of 10 ounces since birth. Question 26 26162

The question is asking which finding in the routine assessment of a 24-hour-old infant requires further evaluation. Let's analyze each option:<br /><br />---<br /><br />### **A. Respiratory rate of 50 breaths/minute**<br />- Normal respiratory rate for a newborn is **30–60 breaths per minute**.<br />- A respiratory rate of 50 breaths/minute falls within the normal range.<br />- **Does not require further assessment.**<br /><br />---<br /><br />### **B. 2 cm bluish-purple area on the sacrum**<br />- This description likely refers to a **Mongolian spot**, which is a common and benign skin finding in newborns, especially in infants with darker skin tones.<br />- Mongolian spots are harmless and do not require further evaluation.<br />- **Does not require further assessment.**<br /><br />---<br /><br />### **C. Edema present along the sagittal suture**<br />- Edema along the sagittal suture could indicate **caput succedaneum** (a common swelling of the scalp due to pressure during delivery) or **cephalohematoma** (a collection of blood under the periosteum).<br />- While caput succedaneum is usually benign and resolves on its own, cephalohematoma may require monitoring for complications like jaundice or infection.<br />- **This finding may require further assessment.**<br /><br />---<br /><br />### **D. Weight loss of 10 ounces since birth**<br />- Newborns typically lose **5–10% of their birth weight** in the first few days after delivery due to fluid loss and limited intake before breastfeeding is fully established.<br />- A weight loss of 10 ounces is likely within the normal range, depending on the infant's birth weight.<br />- **Does not require further assessment.**<br /><br />---<br /><br />### **Correct Answer: C. Edema present along the sagittal suture**<br />This finding may indicate a condition that warrants closer observation or further evaluation to rule out complications.