A nurse is caring for a client

Exhibits

A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up? Select all that apply.

A. A fetal heart rate (FHR) baseline of 170/min indicates fetal tachycardia, which could be due to maternal fever, dehydration, infection, or fetal distress. This requires immediate evaluation by the provider.
B. Early decelerations are a normal finding caused by fetal head compression and do not indicate distress.
C. A temperature of 37.4°C (99.3°F) is within the normal range and does not require reporting.
D. Contractions lasting 80 seconds are within an acceptable range during active labor (typically 60-90 seconds).

The client is at risk for developing transient tachypnea of the newbornand hypoglycemia.

Rationale:

Target 1: Transient Tachypnea of the Newborn (TTN): The newborn has progressively increasing respiratory rates (68 → 72 → 76 breaths/min) along with grunting and mild intercostal retractions. Cesarean birth is a major risk factor for TTN because the absence of labor contractions delays the clearance of fetal lung fluid. TTN typically presents within the first few hours of life with tachypnea and mild respiratory distress, resolving within 24–72 hours.

Target 2: Hypoglycemia: The newborn weighs 4200 g (9 lb 4 oz), indicating macrosomia.

Large-for-gestational-age (LGA) infants are at higher risk for hypoglycemia due to increased insulin production in response to maternal hyperglycemia. Tachypnea can also be a sign of hypoglycemia in neonates.

Incorrect Options:

Tachycardia: The newborn’s heart rate is elevated (154–156 bpm), but mild tachycardia is expected in newborns and is not the primary concern compared to respiratory distress and hypoglycemia risk.

Bronchopulmonary Dysplasia (BPD): BPD is a chronic lung condition primarily seen in preterm infants who require prolonged mechanical ventilation and oxygen therapy. This newborn was term, had clear amniotic fluid, and no intubation, making BPD unlikely.