A nurse is caring for a newborn in the newborn nursery unit.

Exhibits

After reviewing the information in the newborn's electronic medical record (EMR), which of the following findings should the nurse report to the provider? Click to highlight below the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

 

Body system	Findings
Neurologic	Irritability
	Pupil response
Integumentary	Milia on nose and cheeks
	Lanugo on bilateral shoulders
Cardiopulmonary	Axillary temperature
	Respiratory rate
	Apical heart rate
	Lung findings
Gastrointestinal	Stool characteristics
	Abdomen findings

Choice A rationale

Initiating internal fetal heart rate monitoring is an invasive procedure that is not the priority for a non-reassuring fetal heart rate pattern like late decelerations, which often indicate uteroplacental insufficiency. The first step involves non-invasive intrauterine resuscitation measures to immediately improve fetal oxygenation before considering invasive monitoring, unless the external tracing is inadequate.

Choice B rationale

Late decelerations are an indication of uteroplacental insufficiency (decreased blood flow/oxygen to the fetus during the contraction). Assisting the client to a left lateral position is the priority nursing action because it relieves pressure from the gravid uterus on the vena cava, which in turn maximizes venous return to the heart and increases blood flow and oxygen delivery to the placenta and fetus.

Choice C rationale

While uterine tachysystole (excessive frequency of contractions, greater than five in 10 minutes over 30 minutes) can cause late decelerations, palpating for it is not the absolute first action. The immediate priority is to improve fetal oxygenation by repositioning the mother. Palpation for tachysystole, however, is a quick assessment that should follow the repositioning intervention.

Choice D rationale

Increasing the infusion rate of the maintenance IV fluid (an IV fluid bolus) is a critical step in intrauterine resuscitation for late decelerations. It increases maternal blood volume, which can improve placental perfusion. However, repositioning the client is generally the most immediate, least invasive, and first step to correct or improve the blood flow to the placenta and fetus.

Choice A rationale

For a client with moderate abruptio placenta, which involves premature separation of the placenta from the uterine wall, the primary concern is fetal well-being due to impaired oxygen and nutrient exchange, and maternal hemorrhage. Therefore, continuous monitoring of fetal heart rate (FHR) tracings is a priority to assess for signs of fetal compromise (e.g., late decelerations, bradycardia, nonreassuring patterns) and determine the urgency for delivery.

Choice B rationale

Ferning is a microscopic test where a sample of vaginal fluid is allowed to dry on a slide; the characteristic fern pattern indicates the presence of amniotic fluid. This test is used to confirm rupture of membranes. This is not the immediate priority intervention for abruptio placenta, which is focused on managing hemorrhage and fetal distress, and a vaginal examination may be contraindicated if bleeding is severe.

Choice C rationale

Assessing for cervical dilation requires a vaginal examination. While important for determining labor progression, a vaginal examination is often contraindicated in the setting of unexplained vaginal bleeding until a placenta previa is ruled out by ultrasound, as a digital exam could potentially cause a severe hemorrhage if the placenta is covering the cervix. The FHR is a higher priority.

Choice D rationale

Administering oxytocin is a uterotonic agent used to induce or augment labor. In moderate to severe abruptio placenta, if the client is not in active labor or the bleeding is significant, emergency cesarean delivery might be required. Furthermore, the goal is often to deliver the fetus as quickly and safely as possible; oxytocin is not the initial management and could increase uterine tone, potentially worsening the abruption if not used carefully under close monitoring.