Question 26 26162 The nurse is conducting a routlne assessment of a 24-hour-old infant who was delivered vi Sounces, heart rate was 150beats/minute respiratory rate was 59breaths/minute, and the requires further assessment? A Respiratory rate of 59breaths/minute. B 2 cm blulsh purple area on the sacrum. C Edema present along the sagittal suture. D Weight loss of 10 ounces since birth.

In this scenario, the nurse is assessing a 24-hour-old infant. Let's evaluate each option to determine which one requires further assessment:<br /><br />A. **Respiratory rate of 59 breaths/minute**: A normal respiratory rate for a newborn is typically between 30 and 60 breaths per minute. Therefore, a respiratory rate of 59 breaths per minute is within the normal range and does not require further assessment.<br /><br />B. **2 cm bluish purple area on the sacrum**: This could indicate a bruise or a condition such as a Mongolian spot, which is common in newborns and generally harmless. However, if it is a bruise, it might warrant further investigation to rule out any underlying issues.<br /><br />C. **Edema present along the sagittal suture**: Edema along the sagittal suture could be indicative of caput succedaneum, which is a common and usually benign condition resulting from pressure during delivery. It typically resolves on its own without intervention.<br /><br />D. **Weight loss of 10 ounces since birth**: Newborns commonly lose weight after birth, typically up to 7-10% of their birth weight within the first few days. However, a weight loss of 10 ounces should be evaluated in the context of the infant's birth weight to determine if it falls within the expected range.<br /><br />Based on the information provided, option B (the 2 cm bluish purple area on the sacrum) may require further assessment to ensure it is not a bruise or related to another condition that needs attention.