A nurse is caring for a newborn in the maternity unit Exhibits A nurse is assisting in the care of a newborn. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. General: active with strong cry. HEENT: mucous membranes moist. Respiratory: respirations are shallow and irregular. Cardiovascular: S1, S2, no murmur. Musculoskeletal: moves all extremities well and flexed posture. General: active with high-pitched cry. HEENT: mucous membranes moist. Respiratory: respirations are shallow and irregular. Cardiovascular: S1, S2, no murmur. Musculoskeletal: increased muscle tone with tremors noted upon stimulation. Reflexes: positive Babinski, exaggerated Moro, palmar present.