A nurse is caring for a newborn immediately following birth. Exhibits Click to highlight the newborn's assessment findings that require follow-up by the nurse. To deselect a newborn's assessment finding, click on the newborn's assessment finding again. A nurse is caring for a newborn immediately following birth. Nurses' Notes 2100: Newborn has strong, steady cry. Skin tone consistent with genetic background. Acrocyanosis noted on bilateral extremities and hands. Respirations are even and unlabored. Lung fields clear. Brachial pulse regular. Apical heart rate regular. Moves all extremities actively. 2200: Newborn has occasional strong cries. Skin tone consistent with genetic background. Acrocyanosis noted on bilateral extremities and hands. Lanugo noted on the posterior back. Respirations are even and unlabored. Sternal retractions noted. Lung fields with coarse rhonchi noted in bilateral lung fields. Brachial pulse regular. Apical heart rate regular. Moves all extremities actively Vital signs 2100: Temperature 36.5° C (97.7° F) Axillary Heart rate 152/min Respiratory rate 54/min 2200: Temperature 35.7° C (96.3° F) Axillary Heart rate 140/min Respiratory rate 68/min