A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

Choice A rationale:

Applying crushed cabbage leaves to the breasts can be a traditional remedy to help reduce swelling and discomfort associated with engorgement.

Choice B rationale:

Wearing a snug-fitting bra can help provide support to the breasts and reduce discomfort from breast engorgement. It can also help to avoid stimulation of the breasts, which can decrease milk production in a client who is not breastfeeding. This is an appropriate comfort measure for the client.

Choice C rationale:

Stimulating the nipples by squeezing softly can lead to increased milk production and exacerbate breast engorgement. For a client who is not breastfeeding, this action is not recommended and may worsen the engorgement.

Choice D rationale:

Applying ice packs to the breasts can help reduce inflammation and alleviate discomfort from breast engorgement. This is an appropriate comfort measure for the client who is not breastfeeding.

A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old: A blood glucose level of 40 mg/dL is borderline low but expected in the immediate postnatal period, especially if the infant is asymptomatic. Feeding the infant is the first step to address this, and monitoring is usually sufficient unless symptoms of hypoglycemia develop.

B. A hematocrit of 60% in an infant who is 8-hr old: This value is at the upper end of normal for a newborn and may suggest mild polycythemia. However, it does not require urgent notification unless accompanied by symptoms such as respiratory distress or poor perfusion

C. Jaundice in an infant who is 4-hr old: Early-onset jaundice (within the first 24 hours) is not normal and suggests a potentially dangerous underlying condition, such as hemolytic disease of the newborn or infection. Immediate reporting and further evaluation, including bilirubin levels and possible treatment with phototherapy, are essential.

D. Acrocyanosis in an infant who is 2-hr old: Acrocyanosis (bluish discoloration of the hands and feet) is a common and benign finding in the first 24 to 48 hours after birth due to immature circulation. It does not require notification or intervention.