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

A fetal heart rate (FHR) of 150/min with moderate variability is within the normal range (110-160/min) and suggests adequate fetal oxygenation, which is less indicative of a significant Grade 2 abruption. A Grade 2 (moderate) abruption typically involves 20%-50% placental separation, often resulting in fetal distress like persistent late decelerations or tachycardia as a compensatory response to hypoxemia.

Choice B rationale

Placenta previa, not abruption, classically presents with painless, bright red vaginal bleeding due to the placenta covering the cervical os. Placental abruption, caused by premature separation of the placenta from the uterine wall, typically causes bleeding accompanied by significant, severe, and unrelenting abdominal pain due to concealed hemorrhage and uterine irritability.

Choice C rationale

A soft abdomen suggests a relaxed uterus, which is normal. In Grade 2 placental abruption, blood often becomes trapped between the placenta and uterine wall, causing uterine tetany or hypertonicity (increased muscle tone) and rigidity, which presents as a firm or board-like abdomen that is tender to palpation.

Choice D rationale

A heart rate of 120/min (tachycardia) in the client is an expected finding in a moderate (Grade 2) placental abruption. The client is experiencing hypovolemia due to hemorrhage (internal and/or external bleeding), which triggers a compensatory sympathetic nervous system response, increasing the heart rate to maintain cardiac output and tissue perfusion.

Choice A rationale

Misoprostol is a prostaglandin analog used to prevent or treat postpartum hemorrhage by inducing uterine contractions, but it is not the primary intervention for preeclampsia without severe features, which focuses on blood pressure control and seizure prophylaxis.

Choice B rationale

Administering an IV bolus of lactated Ringer's is generally contraindicated in preeclampsia because it can increase the risk of pulmonary edema due to generalized fluid retention and increased capillary permeability characteristic of the disorder. Fluid management should be conservative.

Choice C rationale

Clonus, which is the presence of rhythmic, involuntary muscle contractions, is a sign of hyperreflexia and central nervous system irritability. It indicates worsening preeclampsia and the potential progression to eclampsia (seizures), necessitating close neurological assessment for timely intervention.

Choice D rationale

Restricting daily oral fluid intake can lead to dehydration and is not a standard or necessary practice for preeclampsia management without severe features, unless there is evidence of pulmonary edema or acute kidney injury. The focus is on careful fluid balance, not routine restriction.