A nurse is caring for a 24-year-old female client in the primary health care provider's office.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Choice A rationale

Identifying that the newborn resembles oneself as a baby is a normal and positive aspect of maternal-infant attachment and bonding, representing the "taking-hold" phase of postpartum psychological adjustment, where the mother focuses on the infant and parental role. This demonstrates integration and is not considered a psychosocial concern warranting intervention, indicating healthy psychological adaptation.

Choice B rationale

Reporting fatigue and a desire to sleep is a physiological and expected finding in the immediate postpartum period, largely due to the physical exertion of labor, blood loss, and hormonal shifts. While rest is important, this is considered a normal physical adjustment and not a primary psychosocial concern indicative of maladaptation or mental health issues, unlike severe mood or attachment disturbances.

Choice C rationale

A lack of desire to feed the newborn can signify impaired maternal-infant bonding, emotional withdrawal, or a potential symptom of postpartum mood disorders, such as postpartum depression, which is a significant psychosocial concern. This finding deviates from the expected "taking-hold" phase where the mother is typically focused on caring for and interacting with the infant, necessitating further psychosocial assessment.

Choice D rationale

Discussing a desire to have more children is a normal expression of future family planning and generally indicates a positive, healthy adaptation to the current newborn and the role of motherhood. This thought process does not suggest any immediate psychosocial concern or distress and reflects forward-looking reproductive health considerations and positive family construction.

Choice A rationale: Flat and open anterior and posterior fontanels are normal findings in a newborn. These soft spots allow for brain growth and accommodate molding during birth. The anterior fontanel typically measures 1–4 cm and closes by 18 months, while the posterior fontanel is smaller and closes by 2 months. Their presence and flatness indicate normal intracranial pressure and hydration status, requiring no follow-up unless bulging or sunken.

Choice B rationale: A firm, edematous area on the scalp that does not cross suture lines suggests a cephalohematoma, which is a subperiosteal hemorrhage. This condition is associated with vacuum-assisted deliveries and increases the risk for hyperbilirubinemia due to breakdown of accumulated red blood cells. Cephalohematomas typically resolve spontaneously but require monitoring for jaundice and anemia. Follow-up is essential to assess bilirubin levels and ensure no complications such as infection or calcification.

Choice C rationale: Fine crackles in the lower lung fields may indicate retained fetal lung fluid or transient tachypnea of the newborn (TTN), especially in late preterm infants. While crackles can be benign in the first hours of life, persistence beyond 24 hours warrants evaluation for respiratory distress or infection. Pulmonary auscultation should be repeated, and oxygenation monitored. Crackles may also signal aspiration or pneumonia, necessitating follow-up to rule out pathology.

Choice D rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24–48 hours of life due to immature peripheral circulation. However, persistence beyond this period may indicate poor perfusion or underlying cardiac issues. In this case, the newborn is on day 3, and continued acrocyanosis requires follow-up to assess for hypoxemia, congenital heart defects, or sepsis. Pulse oximetry and cardiovascular evaluation are warranted.

Choice E rationale: Facial bruising is often associated with birth trauma, especially in vacuum-assisted deliveries. While bruising itself may resolve without intervention, it contributes to increased bilirubin production due to hemolysis of extravasated red blood cells. In a newborn already undergoing phototherapy for hyperbilirubinemia, additional bruising increases the risk for worsening jaundice. Follow-up is necessary to monitor bilirubin levels and ensure adequate phototherapy adherence.

Choice F rationale: Moist, pink, and intact oral mucosa indicates good hydration, oxygenation, and absence of mucosal lesions or infection. This finding reflects normal tissue perfusion and integrity. No follow-up is needed unless signs of dehydration, cyanosis, or oral thrush develop. It confirms that feeding is adequate and systemic circulation is intact.

Choice G rationale: A moist umbilical cord with three vessels—two arteries and one vein—is a normal anatomical finding. The presence of three vessels confirms normal fetal circulation and renal development. Moistness indicates appropriate healing without signs of infection. No follow-up is required unless there is foul odor, purulent discharge, or delayed cord separation.

Choice H rationale: Vernix caseosa is a protective, waxy substance found in skin folds of newborns. It provides antimicrobial properties and prevents skin desiccation. Its presence is normal, especially in preterm or late preterm infants. Vernix is gradually absorbed or removed during bathing. No follow-up is needed unless there are signs of skin breakdown or infection.