Newborn Transitioning

Newborn Transitioning

Sarah works in the labor and delivery unit as a transition nurse. Her department has instituted a new bedside transition period where newborn transitioning make the transition to extrauterine life in their mother’s recovery room about an hour after birth. Sarah’s next assignment is a new baby boy with Apgar scores of 8 and 9, born by cesarean about 1 hour ago to Lindsay, a 28-year-old G1. Sarah’s assessment findings of the new baby boy are:

  • Vital signs: axillary temperature 37.0° C, heart rate 145, respiratory rate 75
  • Observations: color pink, respirations rapid and unlabored, good muscle tone, good arm and leg movement
  • Auscultation: breath sounds clear and equal bilaterally, strong heart sounds with a soft murmur, active bowel sounds in all four quadrants
  • Physical assessment: fontanels soft and flat, eyes clear with red reflex in both, ears normal shape and placement, soft and hard palate intact, strong suck, both nares patent, capillary refill less than 2 seconds, both testes descended
  • Measurements: weight 8 pounds 6 ounces, length 20 inches, head circumference 36.2 cm, chest circumference 36.0 cm

As Sarah is charting her findings, Lindsay asks Sarah if everything is OK with her baby. (Learning Objectives 2, 3, and 4)

  1. Which assessment findings for this newborn are abnormal? What is the most likely cause of these abnormal findings?
  2. How would Sarah explain these abnormal findings to Lindsay?
  3. Describe the nursing interventions that Sarah would implement based on these findings.




Newborn Transitioning




Student’s Name







Newborn Transitioning

Every newborn’s breath is a heartfelt testament to the complicated dance of physiological and psychological transformations that disclose during the miraculous procedure of newborn transitioning. Newborn transitioning is an essential and delicate procedure marking the beginning of a baby’s life outside the womb. It encompasses a newborn’s various physiological and psychological transformations to adapt to the outside world (Maguire-Fong & Peralta, 2018). As the baby emerges into the unfamiliar environment, the transition requires significant changes in their respiratory, cardiovascular, and thermoregulatory networks. The first breath taken by a newborn denotes the initiation of independent respiration, with the lungs enlarging and oxygenating the blood. Concomitantly, the cardiovascular network redirects the blood flow, closing of fetal circulation pathways and creating a new circulatory pattern. In addition, the baby’s body should rapidly acclimate to maintain a stable body temperature, as the controlled warmth of the womb no longer surrounds them. Alongside these physiological transformations, newborn transitioning also requires psychological adaptation as the baby starts to perceive and respond to sensory stimuli, creating connections with caregivers and initiating the early phases of bonding. Comprehending and supporting these intricate procedures are essential in equipping optimal care and ensuring the newborn’s well-being during this significant transition period. This paper will explore a case study on Sarah, a labor and delivery unit worker as a transition nurse. From the case scenario, we shall explain the assessment findings of the newborn that are abnormal, the most likely cause of the abnormal findings, how Sarah would explain the abnormal findings to Lindsay, and finally, the nursing interventions that Sarah would execute based on the findings.

The Newborn’s Abnormal Assessment Findings

Based on the equipped assessment findings, most of the newborn’s findings emerge to be within the normal range. Moreover, there are a few abnormal evaluation findings that must be addressed. Firstly, there is a soft murmur existing during the auscultation of the heart sounds. While murmurs can be customary in newborns and may resolve independently, it is essential to observe the baby’s heart function and consult a pediatrician to decide the cause and possible significance of the murmur. In addition, a head circumference of 36.2 centimeters is slightly higher than the average range of newborns, indicating macrocephaly. These findings may vindicate further investigation to rule out any underlying disorder or abnormalities. Comprehensively, while these findings are abnormal, they do not definitely indicate a significant or immediate concern. Moreover, the healthcare provider must share these findings with the pediatrician and progress to observe the baby’s development.

The cause of the Abnormal Findings

Based on the assessment findings equipped, the baby boy has discernible abnormal findings. The vital signs like temperature, heart rate, and respiratory rate are within the usual range for a newborn. Monitoring indicates a pink color, rapid and unlabored respirations, good muscle tone, and arm and leg movement, which are emphatic signs of a healthy transition to extrauterine life. Auscultation discloses clear breath sounds, strong heart sounds with a soft murmur, which can be expected in newborns, and agile bowel sounds (Andrès et al., 2018). The physical evaluation indicates normal findings like soft and flat fontanels, clear eyes with a red reflex, normal ears, complete palate, strong suck, patent nares, descended testes, and regular measurement for weight, length, head perimeter, and chest rim. Therefore, no abnormal findings suggest any underlying health problems or concerns with the baby. Based on the evaluation findings, Sarah can encourage Lindsay that everything emerges to be OK with her baby.

Sarah’s Simplification of Abnormal Findings to Lindsay

Sarah would address Lindsay with empathy and encouragement while explaining the abnormal findings regarding the baby. She would start by recognizing Lindsay’s concern and letting her know that she comprehends how crucial her baby’s well-being is to her. She would then explain that her baby’s status is comprehensively stable, and there is no immediate cause for alarm. She would begin by discussing the Apgar scores, encouraging Lindsay that scores of eight to nine are considered very good and show a healthy transition to the outside world. Sarah would then approach the vital signs, telling Lindsay that her baby’s axillary temperature 37 falls within the usual range for newborns. Equally, the heart rate of 145 beats per minute and respiratory rate of 75 breaths per minute are also within the estimated range for a newborn (Mayor et al., 2023). Heading to the monitoring, she would explain that the baby’s pink color is an emphatic sign, showing good oxygenation. She would emphasize that rapid and unlabored respiration, good muscle tone, and arm and leg movements are all emphatic indications of a healthy baby. She would then approach the auscultation findings. Sarah would explain that clear and justice breath sounds shows that the baby’s lungs are operating well. While there is a soft murmur heard in the heart sounds, she would encourage Lindsay that this is relatively common in newborns and frequently resolves independently without causing any problems.

Concerning the physical evaluation, she would mention that the soft and flat fontanels are normal and a sign of proper brain growth. The clear eyes with a red reflex in both show healthy vision (Toli et al., 2021). The usual shape and placement of the ears, intact and smooth and hard palate, strong suck, and patent nares all indicate that the baby’s facial features and airways are operating accordingly. She would also inform Lindsay that the baby’s capillary refill time of fewer than two seconds indicates good circulation. Finally, she would explain that the descent of both testes is a usual finding in a newborn male. During the explanation, she maintained a calm and supportive attitude, reassuring Lindsay to ask questions and provide further explanations if required. Sarah would emphasize that while minor differences and findings exist, her baby’s condition is comprehensively healthy, and there is no cause for immediate concern.

The nursing Interventions Sarah to Implement Based on the Findings

Based on the assessment of the newborn baby boy, Sarah would execute numerous nursing interventions to ensure the well-being and safety of the baby. First, since the vital signs show an average axillary temperature, heart rate, and respiratory rate, she would progress to observe these parameters regularly to note any possible changes or abnormalities. Sarah would also evaluate the color of the baby’s skin periodically, ensuring it remains pink to indicate adequate oxygenation. She would also progress to monitor the baby’s respirations closely, noting that they are rapid and unlabored, which is an emphatic finding. Moreover, she would maintain attentiveness in observing respiratory efforts to detect signs of distress or challenges. The excellent muscle tone and arm and leg movement indicate that the baby has good neuromuscular growth, but she would progress to evaluate for any abnormalities in muscle strength or coordination. She identified clear and equal breath sounds bilaterally throughout auscultation, showing good lung operation. The existence of a strong heart sound with a soft murmur would encourage her to closely observe the baby’s cardiac status and report the murmur to the healthcare provider for further assessment. The agile bowel sounds in all four quadrants would assure Sarah that the baby’s gastrointestinal system is operating accordingly.

Sarah would also conduct a thorough physical evaluation of the baby’s head and facial structures. The soft and flat fontanels show normal intracranial pressure, and the clear eyes with red reflex show average visual growth. The standard shape and placement of the ears suggest no apparent abnormalities. Sarah would ensure the integrity of the baby’s soft and hard palate, which emerges intact. The robust and patent nares show the baby’s ability to feed successfully and breathe comfortably through the nose. Finally, Sarah would document the baby’s weight, length, head perimeter, and chest perimeters as they equip essential baseline data for future growth evaluation. When Lindsay asks if everything is alright with the baby, she can provide reassurance based on the empathic evaluation findings. She can explain that the baby’s vital signs, physical appearance, and growth markers are within normal range, showing a healthy transition to extrauterine life. Sarah can also provide information about the interventions she has executed to observe the baby’s well-being and assure Lindsay that she will progress to monitor the baby during the recovery period closely.


In conclusion, the newborn baby boy’s evaluation findings in Sarah’s care indicate a smooth and healthy transition to extrauterine life. All vital signs, monitoring, auscultation outcomes, physical evaluation findings, and measurement fall within the normal range, demonstrating an emphatic outcome. Sarah can confidently assure Lindsay that her baby is doing well. The absence of abnormal findings indicates that the baby’s transition procedure has been effectual, equipping the new mothers with reassurance and peace of mind. Sarah’s diligent observation and inclusive evaluation contribute to the baby’s and Lindsay’s overall well-being and care throughout this crucial period of newborn transitioning.





Andrès, E., Gass, R., Charloux, A., Brandt, C., & Hentzler, A. (2018). Respiratory sound analysis in the era of evidence-based medicine and the world of medicine 2.0. Journal of Medicine and Life11(2), 89.

Maguire-Fong, M. J., & Peralta, M. (2018). Infant and toddler development from conception to age 3: What babies ask of us. Teachers College Press.

Mayor, D., Steffert, T., Datseris, G., Firth, A., Panday, D., Kandel, H., & Banks, D. (2023). Complexity and entropy in physiological signals (ceps): Resonance breathing rate assessed using measures of fractal dimension, heart rate asymmetry and permutation entropy. Entropy25(2), 301.

Toli, A., Perente, A., & Labiris, G. (2021). Evaluation of the red reflex: An overview for the pediatrician. World Journal of Methodology11(5), 263.

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