A nurse is collecting data from a newborn immediately after delivery by a client who was at 42 weeks of gestation. Which of the following findings should the nurse expect?

Choice A:

Temperature is not a priority finding to report to the provider. The newborn's temperature may vary slightly depending on the environment and the method of measurement. A normal temperature range for a newborn is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice B:

Respiratory findings are important to report to the provider because the newborn had a low Apgar score at 1 minute and required positive pressure ventilation and oxygen. The nurse should assess the newborn's respiratory rate, effort, breath sounds, and oxygen saturation. Any signs of respiratory distress, such as tachypnea, grunting, retractions, nasal flaring, or cyanosis, should be reported immediately.

Choice C:

Serum glucose is a critical finding to report to the provider because the newborn is at risk for hypoglycemia due to the abruptio placenta and the emergency cesarean birth. Hypoglycemia can cause neurological damage and seizures in newborns. A normal serum glucose level for a newborn is 40 to 60 mg/dL.

Choice D:

Hematocrit is a significant finding to report to the provider because the newborn may have polycythemia or anemia due to the abruptio placenta and the blood loss during delivery.

Polycythemia can cause hyperviscosity and thrombosis, while anemia can cause hypoxia and shock. A normal hematocrit level for a newborn is 42% to 65%.

Choice E:

White blood cell count is not a priority finding to report to the provider. The newborn's white blood cell count may be elevated due to the stress of birth or a maternal infection. A normal white blood cell count for a newborn is 9,000 to 30,000/mm3.

Choice F:

Hemoglobin is an important finding to report to the provider because the newborn may have polycythemia or anemia due to the abruptio placenta and the blood loss during delivery.

Hemoglobin is the main component of red blood cells that carries oxygen to the tissues. A normal hemoglobin level for a newborn is 14 to 24 g/dL.

Choice G:

Heart rate is a vital finding to report to the provider because the newborn had a non- reassuring fetal heart rate during labor and delivery. The nurse should monitor the newborn's heart rate and rhythm for any signs of bradycardia, tachycardia, or arrhythmias. A normal heart rate range for a newborn is 110 to 160 beats per minute.

Choice A:

Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.

Choice B:

Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.

Choice C:

Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.

Choice D:

Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.

Choice E:

Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.