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. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.

Irregular contractions alone are not necessarily concerning. However, if they are not felt by the client, it may indicate decreased fetal movement. Further evaluation is needed to ensure the baby’s well-being.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.

An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period:This finding is reassuring.A reactive NST (with accelerations in FHR) indicates that the baby is healthy and responsive to moveme.

C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.

The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.

D. Three fetal movements perceived by the client in a 20-min testing period.

Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.
Irregular contractions of short duration that are not perceived by the client are not typically concerning during a nonstress test (NST). The primary focus of an NST is to assess fetal heart rate patterns in response to fetal movement and uterine activity. As long as these contractions do not lead to decelerations or other signs of fetal distress, they are not usually indicative of a problem.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.
This is the correct answer. While fetal heart rate accelerations in response to fetal movement are typically reassuring during an NST, an acceleration of 150 beats per minute above the baseline heart rate, lasting 10 seconds, could indicate fetal distress or compromise. Such a significant increase may suggest that the fetus is having difficulty compensating for stress or may be experiencing hypoxia, necessitating further evaluation.

C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.

D. Three fetal movements perceived by the client in a 20-min testing period.
Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.

A. Heart rate 90/min:

A heart rate of 90 beats per minute is within the normal range for a postpartum client. While tachycardia (an elevated heart rate) can be a sign of hemorrhage, a heart rate of 90/min alone is not necessarily indicative of hemorrhage.

B. Blood pressure 88/40 mm Hg:

A blood pressure of 88/40 mm Hg is low and may indicate hypotension, which can be a sign of hemorrhage. Hypotension, especially when accompanied by other signs such as tachycardia, pallor, or altered mental status, can indicate significant blood loss.

C. Urinary output 40 mL/hr:

A urinary output of 40 mL/hr is low and may indicate decreased perfusion, which can be a sign of hemorrhage. Postpartum hemorrhage can lead to decreased blood volume, resulting in decreased organ perfusion and urine output.

D. Moderate rubra lochia:

Lochia rubra, which is red-tinged vaginal discharge occurring in the first few days after childbirth, is normal postpartum. However, the presence of moderate rubra lochia alone is not a definitive sign of hemorrhage. It's essential to assess the amount, color, and consistency of lochia along with other clinical signs and symptoms.