1. A nurse is caring for a newborn immediately following birth.

Exhibit 1

Medical History

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor

Exhibit 2

Vital Signs

Apgar:

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Exhibit 3

Medications

Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth

Exhibit 4

Laboratory Findings

WBC count 15,000mm (9,000 to 30,000/mm)

Hgb 19 g/dl (15 to 24 g/dL)

HCt 57% (44% to 70%)

Blood glucose 44 mg/dl (40 to 60 mg/dL)

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or indication that the client's condition is worsening

A. Perform fetal scalp stimulation:

Fetal scalp stimulation involves applying pressure to the fetal scalp during a vaginal examination to elicit a response from the fetus, such as an acceleration of the fetal heart rate. While this can provide additional information about fetal well-being, it is not the initial priority when late decelerations are observed on the fetal monitor. The focus should first be on interventions aimed at improving fetal oxygenation to address the underlying cause of the late decelerations.

B. Administer oxygen via a face mask:

Administering oxygen to the mother is a priority intervention when late decelerations of the fetal heart rate are observed on the external fetal monitor. Late decelerations often indicate uteroplacental insufficiency, where the fetus is not receiving adequate oxygenation. Administering oxygen to the mother helps increase oxygen levels in her blood, improving oxygen delivery to the fetus and potentially mitigating the effects of uteroplacental insufficiency.

C. Elevate the client's head:

Elevating the client's head is not indicated when late decelerations are observed. This position could potentially compromise maternal-fetal circulation by reducing blood flow to the placenta. Maintaining a side-lying or semi-Fowler's position is often recommended to improve blood flow to the placenta and enhance fetal oxygenation.

D. Decrease the rate of IV fluids:

Adjusting the rate of IV fluids may be considered in some situations, such as if there is evidence of fluid overload or if the mother is receiving excessive amounts of IV fluids. However, it is not typically the initial intervention for addressing late decelerations. The focus should first be on interventions aimed at improving maternal-fetal oxygenation, such as administering oxygen and positioning the client appropriately.

A. The client will verbalize appropriate car seat safety.

Teaching about car seat safety is important for the mother's understanding of infant care, but it is not specifically related to the taking-in phase, which primarily focuses on the mother's adjustment and recovery.

B. The client will demonstrate proper bathing of the infant.

Similarly, teaching about infant care, such as proper bathing techniques, is important but may be more appropriate for later phases of postpartum adjustment when the mother is more focused on caring for her infant.

C. The client will identify individual family member roles.

This goal may be more relevant to later phases of postpartum adjustment when the mother begins to integrate the new baby into the family unit. During the taking-in phase, the focus is primarily on the mother's own adjustment.

D. The client will have adequate nutritional intake.

This goal aligns with the priorities of the taking-in phase, which include the mother's physical recovery and well-being. Adequate nutritional intake is essential for postpartum recovery and breastfeeding, making it an appropriate goal for this phase.