A nurse is assessing a newborn immediately following a vaginal birth.
For which of the following findings should the nurse intervene?

Sternal retractions.

Acrocyanosis.

Molding.

Vernix caseosa.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Sternal retractions indicate increased respiratory effort and can be a sign of respiratory distress in a newborn. This occurs when the infant is struggling to inhale, causing the chest wall to visibly pull inward with each breath due to negative pressure, and requires immediate intervention.

Choice B rationale

Acrocyanosis, characterized by bluish discoloration of the hands and feet, is a common and normal finding in newborns during the first 24 to 48 hours after birth. It is due to immature peripheral circulation and does not typically indicate a need for intervention.

Choice C rationale

Molding is the overlapping of the fetal skull bones during passage through the birth canal. This is a normal adaptation during vaginal birth and typically resolves spontaneously within a few days, thus requiring no intervention.

Choice D rationale

Vernix caseosa is a whitish, cheesy substance covering the skin of many newborns, providing protection and lubrication in utero. Its presence is normal and beneficial, often providing hydration and antimicrobial properties to the skin post-birth.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.

Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.

Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.

Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.

Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.

A. A client who is at 12 weeks of gestation and reports not having felt the fetus move. B. A client who is at 28 weeks of gestation and has a fetal heart rate of 160/min via Doppler. C. A client who is at 38 weeks of gestation and has 2+ deep tendon reflexes. D. A client who is at 36 weeks of gestation and reports blurred vision.

Correct Answer is D

Explanation

Choice A rationale

A client at 12 weeks of gestation not feeling fetal movement is expected. Fetal movement, or quickening, typically begins between 16 and 20 weeks of gestation for primigravidas and earlier for multigravidas. At 12 weeks, the fetus is still small and movements are not usually strong enough to be consistently perceived by the mother, thus this finding is not immediately concerning.

Choice B rationale

A fetal heart rate (FHR) of 160/min at 28 weeks of gestation is within the normal range, which is typically 110-160 beats/min. A normal FHR indicates adequate fetal oxygenation and well-being. Therefore, this finding does not suggest an emergent situation requiring immediate provider assessment.

Choice C rationale

Deep tendon reflexes (DTRs) graded as 2+ are considered normal. This grading indicates an average, brisk reflex response. Abnormal DTRs, such as hyperreflexia (3+ or 4+), can be indicative of preeclampsia, but a 2+ finding is physiological and does not warrant immediate concern.

Choice D rationale

Blurred vision in a client at 36 weeks of gestation can be a symptom of preeclampsia, a serious hypertensive disorder of pregnancy. This condition can lead to severe complications such as eclampsia, placental abruption, or HELLP syndrome, requiring immediate medical evaluation and intervention to prevent adverse maternal and fetal outcomes.

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A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene?

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A nurse is assessing a newborn immediately following a vaginal birth.
For which of the following findings should the nurse intervene?