A nurse is caring for a term newborn who is 48 hr old.

Physical Examination

• High-pitched cry
• Mild tremors when disturbed Increased muscle tone Sneezing six times within 1 hr Excessive sucking
• Color: Consistent with genetic background Excoriation of the chin
• Watery stools Projectile vomiting
• Hyperactive Moro reflex

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Regurgitation: Sign of Potential Worsening Condition - Regurgitation may indicate a feeding problem or gastrointestinal issue, which could worsen if not addressed.

Mottling: Sign of Potential Worsening Condition - Mottling can be a sign of poor perfusion or circulation, indicating potential worsening of the newborn's condition.

Transient strabismus: Sign of Potential Improvement - Transient strabismus, or crossed eyes, is common in newborns and often resolves on its own, indicating potential improvement.

Continuous high-pitched cry: Sign of Potential Worsening Condition - Continuous high- pitched crying may indicate discomfort or underlying pathology, suggesting potential worsening. Respiratory rate 70/min: Sign of Potential Worsening Condition - An increased respiratory rate may indicate respiratory distress or another issue, suggesting potential worsening.

Loose stools: Sign of Potential Worsening Condition - Loose stools in a newborn can be a sign of gastrointestinal upset or infection, indicating potential worsening of the newborn's condition.