A nurse is collecting data from a newborn who is 4 hours old.
Which of the following findings should the nurse report to the provider?

Choice A rationale

Requesting a parent to verify the newborn's name is an important part of the identification process, but it is not the primary method for confirming identity directly on the newborn. Verifying identity relies on objective comparison of identifying markers on both the infant and the parent for accuracy.

Choice B rationale

Checking the newborn's footprint sheet with the medical record is a valid identification method, but typically occurs when the newborn is admitted or for more permanent records. For immediate transport, a direct comparison of armbands between the newborn and parent is the most efficient and readily verifiable method.

Choice C rationale

Asking a parent to state the newborn's date of birth provides information about the newborn. However, this relies on parental recall and is not a direct physical confirmation of the newborn's identity. Physical identifiers like matching band numbers offer a more secure and immediate verification.

Choice D rationale

Comparing numbers on the newborn's band to the parent's band is the most secure and immediate method to confirm identity prior to transport. This ensures that the correct newborn is being given to the designated parent, preventing potential mix-ups and upholding critical safety protocols in maternity care.

Choice A rationale

A blood pressure (BP) of 105/62 mm Hg, while slightly on the lower side of what might be considered a typical adult range (e.g., 120/80 mm Hg), is often within acceptable limits for a postoperative adolescent, especially considering potential mild vasodilation from opioid use. A normal range for adolescent blood pressure can vary, but generally, hypotension is defined as a systolic BP less than 90 mm Hg or symptomatic drop. This finding, while noted, is not immediately life-threatening compared to compromised respiratory function.

Choice B rationale

Urinary retention is a common adverse effect of opioid analgesics due to their anticholinergic-like effects on bladder detrusor muscle contractility and increased sphincter tone. While uncomfortable and requiring intervention (e.g., straight catheterization), it is not an immediate life-threatening concern compared to respiratory depression. A normal bladder capacity is approximately 300-500 mL, and the urge to void typically occurs at 150-200 mL. Persistent urinary retention can lead to bladder distention, pain, and increased risk of urinary tract infection, but it doesn't pose the same acute physiological threat as respiratory depression.

Choice C rationale

A respiratory rate of 11/min is a finding that warrants immediate attention and is the nurse's priority. Opioid analgesics, such as morphine, are known to cause respiratory depression by acting on opioid receptors in the brainstem, decreasing the sensitivity of the respiratory center to carbon dioxide. A normal respiratory rate for an adolescent typically ranges from 12 to 20 breaths per minute. A rate of 11/min is considered bradypnea and indicates potential hypoventilation, which can lead to hypoxemia and hypercapnia, posing a significant risk to the patient's oxygenation and overall physiological stability.

Choice D rationale

Blurred vision can be an adverse effect of opioid medications, often related to miosis (pupil constriction) or effects on accommodation. While it can impair the patient's comfort and ability to ambulate safely, it is not a life-threatening priority in the immediate postoperative period compared to respiratory compromise. This visual disturbance typically resolves as the medication is metabolized and excreted. Normal visual acuity is typically 20/20. .