A nurse is caring for a newborn who was born at 37 weeks of gestation and is 12 hours old.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn's progress.

Choice A reason:

The nurse's priority in this situation is the client's blood pressure of 80/56 mm Hg. Opioid epidural analgesia can cause a drop in blood pressure, known as hypotension. Hypotension can be a significant concern during labor, as it may reduce blood flow to the placenta and compromise the baby's well-being. Therefore, it is crucial for the nurse to address this finding promptly to prevent any adverse effects on both the mother and the baby. The nurse may need to administer intravenous fluids, adjust the dosage of the opioid medication, or take other appropriate actions to raise the blood pressure to a safer level.

Choice B reason:

While profuse itching (choice B) can be a common side effect of opioids, it is not the nurse's priority in this situation. Itching, also known as pruritus, can be managed with antihistamines or other supportive measures, but it is not an immediate threat to the client's well-being.

Choice C reason:

The client reporting weakness of the lower extremities (choice C) is an expected side effect of epidural analgesia. Epidurals can cause temporary paralysis or weakness in the lower body due to the local anesthetic's effects on the nerves. While it's essential to monitor and support the client during this time, it is not the priority over the potentially dangerous drop in blood pressure.

Choice D reason:

A temperature of 38.2°C (100.8 F) (choice D) may indicate a fever, but it is not the nurse's priority in this specific situation of opioid epidural analgesia during labor. Fever during labor could have various causes, and the nurse should investigate and manage it appropriately. However, addressing the client's blood pressure takes precedence, as hypotension can have immediate and significant consequences.

Choice A reason:

This is incorrect because WIC does not provide immunizations for high-risk infants and children. Immunizations are provided by other health care services, which WIC may refer participants to.

Choice B reason:

This is incorrect because WIC does not screen for infants with developmental disorders. WIC provides nutrition education and referrals to other health and social services but does not diagnose or treat any medical conditions.

Choice C reason:

This is correct because WIC provides supplemental food supplies to low-income pregnant or breastfeeding women, as well as infants and children up to age 5 who are at nutritional risk. The food packages are designed to meet the special nutritional needs of the participants and include items such as fruits, vegetables, milk, cheese, cereal, bread, juice, peanut butter, eggs, and infant formula.

Choice D reason:

This is incorrect because WIC does not provide well-child examinations for infants and children living at the poverty level. WIC may refer participants to other health care services that provide such examinations but do not conduct them themselves.