A nurse is caring for a newborn 4 hours after their birth.
Which of the following findings should the nurse report to the provider?

Soft grunting noises with respiration.

Positive Babinski reflex.

Pale blue hands and feet.

Blood-tinged discharge from the vagina.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Soft grunting noises during expiration are a sign of mild to moderate respiratory distress in a newborn. Grunting is the newborn's attempt to keep the alveoli open by increasing Positive End-Expiratory Pressure (PEEP), suggesting decreased lung compliance or insufficient surfactant. This finding requires immediate notification of the provider for evaluation and potential intervention.

Choice B rationale

A positive Babinski reflex, which involves the great toe dorsiflexing and the other toes fanning out upon stroking the sole of the foot, is a normal neurological finding in a newborn and infant. This reflex persists until about 1 to 2 years of age as the central nervous system matures, and therefore does not require reporting.

Choice C rationale

Acrocyanosis, which is pale blue hands and feet with pinkish trunk and mucous membranes, is a common and normal finding in a newborn during the first 24 to 48 hours after birth due to immature peripheral circulation and cold exposure. This peripheral vasoconstriction resolves spontaneously and is not typically reported unless accompanied by central cyanosis.

Choice D rationale

Blood-tinged discharge from the vagina, often called pseudomenstruation, is a normal, transient finding in female newborns. It is caused by the withdrawal of maternal estrogen hormones following birth, leading to a minor sloughing of the uterine endometrium, and does not indicate a pathological condition requiring immediate reporting.

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Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"B,C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"B,C"}}

Explanation

Vaginal bleeding

Bleeding occurs in placenta previa due to partial or total implantation of the placenta over the cervical os, leading to painless bright red bleeding from disrupted placental vessels. It also occurs in preterm labor when cervical effacement and dilation disrupt small cervical vessels, producing light bleeding or spotting. In abruptio placenta, bleeding is dark red and may be concealed or apparent, resulting from premature placental detachment and rupture of maternal vessels in the decidua basalis.

Uterine contractions

Regular uterine contractions every 2 to 3 minutes with cervical change are diagnostic of preterm labor, resulting from premature activation of uterine oxytocin receptors and prostaglandin release before 37 weeks. In abruptio placenta, contractions are often strong and sustained (hypertonic uterus) due to myometrial irritability from bleeding into the decidual layer. Placenta previa, however, typically presents with painless bleeding and a soft, relaxed uterus without contractions because the uterine muscle tone remains unaffected.

Cervical dilation

Cervical dilation indicates preterm labor, as biochemical changes in the cervix from increased prostaglandin and relaxin activity cause collagen breakdown and effacement before term. This process reflects uterine activation sequence initiation leading to potential preterm birth. In placenta previa, the cervix may remain closed despite bleeding because bleeding originates from placental implantation, not cervical change. Abruptio placenta rarely involves dilation unless labor progresses secondarily after placental separation, thus cervical dilation is not a key feature.

Abdominal tenderness

Abdominal tenderness is characteristic of abruptio placenta, caused by bleeding between the uterine wall and placenta leading to myometrial irritability, uterine rigidity, and ischemic pain. The trapped blood increases intrauterine pressure, stimulating pain receptors in the myometrium and stretching the uterine serosa. Placenta previa presents with a soft, nontender abdomen because bleeding is external and not associated with uterine muscle involvement. Preterm labor generally causes back discomfort or cramping, not localized abdominal tenderness.

Client report of low back pain

Low back pain is prominent in preterm labor, resulting from referred pain due to rhythmic uterine contractions transmitted through the lumbosacral plexus and pelvic nerves. It reflects early cervical change and uterine irritability. In abruptio placenta, the back pain may occur secondary to uteroplacental separation and posterior placental bleeding irritating the parietal peritoneum. Placenta previa typically lacks pain or back discomfort since bleeding occurs without uterine or peritoneal irritation.

A. Cervical findings B. Weeks of gestation C. Fetal heart rate D. Vaginal discharge E. Fetal presentation

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

Explanation

Choice A rationale: The cervix being closed and thick at 42 weeks gestation is unfavorable and increases the risk for labor complications. At this stage, the cervix should ideally be effaced and dilated to allow for labor progression. A closed, thick cervix indicates poor readiness for labor, which may necessitate induction with cervical ripening agents. Failure of the cervix to ripen increases the risk of prolonged labor, failed induction, and cesarean delivery, making this a significant complication risk factor.

Choice B rationale: Being at 42 weeks gestation is post-term, which increases the risk for labor complications. Post-term pregnancy is associated with oligohydramnios, macrosomia, meconium aspiration, and placental insufficiency. These conditions can lead to fetal distress, shoulder dystocia, and increased rates of operative delivery. Therefore, advanced gestational age beyond 41 weeks is a recognized risk factor for complications, requiring close monitoring and often induction of labor to reduce maternal and neonatal morbidity.

Choice C rationale: A fetal heart rate of 150/min is within the normal baseline range of 110 to 160 beats per minute. This indicates adequate fetal oxygenation and no evidence of tachycardia or bradycardia. Since the FHR is normal and reassuring, it does not increase the risk for labor complications. Continuous monitoring is still important, but this specific finding is not a complication risk factor.

Choice D rationale: Clear to white mucus-like vaginal discharge is a normal physiologic finding in pregnancy, known as leukorrhea. It results from increased estrogen and cervical gland activity. This type of discharge is not associated with infection, rupture of membranes, or preterm labor. Since it is expected and benign, it does not increase the risk for labor complications. Only abnormal discharges such as foul-smelling, green, or bloody secretions would be concerning.

Choice E rationale: Vertex presentation, specifically left occiput anterior, is the most favorable fetal position for vaginal delivery. It allows for optimal alignment of the fetal head with the maternal pelvis, facilitating descent and rotation during labor. Malpresentations such as breech or transverse would increase the risk for complications, but vertex LOA is ideal. Therefore, this finding is favorable and does not increase the risk for labor complications.

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A nurse is caring for a newborn 4 hours after their birth. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"B,C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"B,C"}}

Explanation

A nurse is caring for a female client who is at 42 weeks of gestation in the prenatal clinic. Exhibits Which of the following findings are factors that increase the risk for potential labor complications? Select all that apply.

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

Explanation

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A nurse is caring for a newborn 4 hours after their birth.
Which of the following findings should the nurse report to the provider?