A nurse is planning care for a newborn who is small for gestational age (SGA) Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Choice A rationale:

The normal WBC count during pregnancy can vary, but a count of 11,000/mm³ is within an acceptable range. During pregnancy, the WBC count can be slightly elevated due to physiological changes in the body to support the growing fetus.

Choice B rationale:

The normal hemoglobin level during pregnancy is generally around 11 to 12.5 g/dL. Therefore, a hemoglobin level of 11.2 g/dL falls within the normal range, and the nurse does not need to report this finding.

Choice C rationale:

The normal hematocrit (Hct) during pregnancy can vary, but a level of 34% is within the acceptable range. Hct levels can be lower during pregnancy due to increased plasma volume, leading to a mild physiological anemia of pregnancy.

Choice D rationale:

The normal platelet count during pregnancy is typically around 150,000 to 400,000/mm³. With a platelet count of 140,000/mm³, this is slightly below the lower end of the normal range. Thrombocytopenia during pregnancy can increase the risk of bleeding, both during childbirth and postpartum, so the nurse should report this finding to the provider for further evaluation and management.

Choice A rationale:

Assisting the family in identifying prior coping skills is a valuable nursing intervention, but it is not the priority action in this situation. The client's feelings of sadness and lack of energy raise concerns about postpartum depression, and the nurse should address potential harm to the newborn first.

Choice B rationale:

This is the priority action by the nurse. The client's symptoms are indicative of postpartum depression, and the nurse must assess if she has considered harming her newborn. This assessment is crucial for the safety and well-being of both the mother and the baby.

Choice C rationale:

Anticipating a prescription for an antidepressant may be appropriate once a proper assessment and diagnosis are made, but it is not the priority action at this stage. Assessing for potential harm to the newborn takes precedence.

Choice D rationale:

Reinforcing postpartum and newborn care discharge teaching is essential for the client's well- being. However, it is not the priority action when the client is showing signs of postpartum depression and possible harm to the newborn.