A nurse is attending to a newborn who was delivered at 39 weeks of gestation and is now 36 hours old.

The newborn has been breastfeeding 3 to 4 times per day and has voided once since birth but has not passed meconium stool yet.

Which of the following observations should the nurse report to the provider?

Choice A rationale
The newborn’s symptoms of jitteriness, weak cry, mottled extremities with acrocyanosis, and rapid, unlabored respirations are indicative of hypoglycemia. Hypoglycemia in the newborn period can be caused by several factors, including maternal diabetes (gestational or pre- existing), preterm birth, and sepsis. The nurse should take actions to address this condition, such as ensuring the newborn is warm, initiating early feeding to provide the newborn with glucose, and monitoring blood glucose levels.
Choice B rationale
Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can cause a wide range of symptoms such as excessive crying, poor feeding, and seizures. However, the symptoms described in the question are more indicative of hypoglycemia.
Choice C rationale
Cold stress can occur in newborns who are unable to maintain their body temperature within a normal range. While some of the symptoms described, such as mottled skin and acrocyanosis, can occur with cold stress, the presence of jitteriness and a weak cry are more indicative of hypoglycemia.
Choice D rationale
Respiratory Distress Syndrome (RDS) is a common problem in premature babies and is caused by a lack of surfactant in the lungs. While rapid, unlabored respirations can be a sign of RDS, the other symptoms described in the question, such as jitteriness and a weak cry, are not typically associated with RDS2.

Choice A rationale
Peripheral edema 2+ in bilateral lower extremities is a common finding in the postpartum period and does not necessarily indicate a problem. It can result from the normal fluid shifts that occur after delivery.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated and could indicate the development of postpartum hypertension, a condition that can lead to serious complications such as stroke. This finding necessitates immediate follow-up.
Choice C rationale
Lateral deviation of the uterus could indicate a full bladder, which can interfere with uterine contractions and lead to increased bleeding. This finding necessitates immediate follow-up.
Choice D rationale
Deep tendon reflexes 1+ are within normal limits and do not necessitate immediate follow-up.
Choice E rationale
A large amount of lochia rubra could indicate postpartum hemorrhage, a potentially life- threatening condition. This finding necessitates immediate follow-up.