A nurse is caring for a newborn who is 30 minutes old following a spontaneous vaginal birth. The birth parent noted dark brown- greenish amniotic fluid during labor. The newborn was delivered at 42 weeks gestation. Apgar scores were 8 at 1 minute and 9 at 5 minutes.

Exhibits

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? Drag one condition and one client finding to fill in each blank in the following sentence.

The condition that poses the greatest risk to the newborn is

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due to

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.

Choice A rationale

As an advocate, the nurse acts to protect the patient’s rights and helps them to speak for themselves. This includes supporting the patient’s decisions, even when these decisions might not be in line with the nurse’s personal beliefs.

Choice B rationale

As a manager, the nurse coordinates activities of members of the nursing staff in delivering nursing care, and oversight ensures that care is safe, effective, and patient-centered.

Choice C rationale

As a caregiver, the nurse assists patients with meeting their physical, psychological, and developmental needs. This role involves direct patient care activities.

Choice D rationale

As an educator, the nurse works to enhance patients’ knowledge about their health and care, promoting health behaviors and self-care skills.

Essential

1. Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.

2. Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.

3. Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

1. Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

1. Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.

2. Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.