A nurse is reinforcing teaching to a client who is at 28 weeks of gestation and reports heroin use.
Which of the following statements should the nurse include in the teaching?

Choice A rationale: A full-term vaginal delivery is a normal and expected finding. Term gestation ranges from 37 to 42 weeks, and vaginal delivery is a common mode of birth associated with fewer complications than cesarean delivery. This finding does not indicate any abnormality or need for follow-up, as it reflects a standard, uncomplicated birth process.

Choice B rationale: APGAR scores of 7 at 1 minute and 9 at 5 minutes are within the normal range. A score of 7 to 10 is considered reassuring, indicating that the newborn is adapting well to extrauterine life. The improvement from 7 to 9 suggests effective transition and no ongoing distress, so no follow-up is required for this finding.

Choice C rationale: A weight of 4,224 g (9 lb 5 oz) classifies the newborn as macrosomic, which is defined as a birth weight over 4,000 g. Macrosomia increases the risk for neonatal hypoglycemia due to hyperinsulinemia from in utero exposure to maternal glucose. This condition requires close monitoring of blood glucose levels and feeding effectiveness to prevent complications like seizures or neurologic injury.

Choice D rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is a common and benign finding in newborns during the first 24 to 48 hours of life. It results from immature peripheral circulation and does not indicate central cyanosis or hypoxia. Therefore, it is not a finding that requires follow-up unless it persists or is accompanied by other signs of distress.

Choice E rationale: A heart rate of 150/min, respiratory rate of 45/min, and rectal temperature of 36.5°C (97.7°F) are all within normal neonatal ranges. Normal heart rate is 120–160/min, respiratory rate is 30–60/min, and rectal temperature is 36.5–37.5°C. These values indicate stable vital signs and do not necessitate follow-up.

Choice F rationale: Difficulty latching during initial breastfeeding attempts may indicate poor feeding effectiveness, which is a concern in the context of neonatal hypoglycemia. Inadequate intake can exacerbate low glucose levels and delay stabilization. This finding requires follow-up to ensure the infant is feeding effectively and maintaining adequate glucose levels.

Choice G rationale: Jitteriness and abnormal crying are neurologic signs that may indicate hypoglycemia, hypocalcemia, or neurologic dysfunction. In this case, the newborn’s glucose was 35 mg/dL, below the normal threshold of 40–45 mg/dL. These symptoms warrant follow-up to monitor for recurrence and ensure resolution with feeding and glucose stabilization.

Choice H rationale: A temperature of 36.3°C (97.3°F) is slightly below the normal range of 36.5–37.5°C, indicating mild hypothermia. Mild hypotonia in conjunction with hypoglycemia and low temperature suggests systemic instability. These findings require follow-up to ensure thermoregulation and neurologic tone normalize with appropriate interventions.

Choice A rationale

Elevated maternal serum alpha-fetoprotein (MSAFP) levels are highly suggestive of neural tube defects (NTDs) such as spina bifida and anencephaly. Alpha-fetoprotein (AFP) is a glycoprotein produced by the fetal liver and yolk sac. In NTDs, the incomplete closure of the neural tube allows for leakage of AFP into the amniotic fluid and subsequently into the maternal bloodstream, leading to elevated serum levels.

Choice B rationale

Phenylketonuria (PKU) is an autosomal recessive metabolic disorder characterized by a deficiency in the enzyme phenylalanine hydroxylase, leading to an accumulation of phenylalanine. It is typically identified through newborn screening, not through elevated maternal serum alpha-fetoprotein levels. MSAFP screening is not used for the diagnosis or suspicion of PKU.

Choice C rationale

Trisomy 21, also known as Down syndrome, is a chromosomal disorder caused by the presence of an extra copy of chromosome 21. While maternal serum screening for Trisomy 21 typically involves assessing multiple markers, including alpha-fetoprotein, low levels of MSAFP, in conjunction with abnormal levels of other markers like human chorionic gonadotropin (hCG) and unconjugated estriol, are generally indicative of Trisomy 21. Elevated AFP is not characteristic.

Choice D rationale

Hemophilia is a group of hereditary bleeding disorders caused by deficiencies in specific blood clotting factors, most commonly factor VIII (hemophilia A) or factor IX (hemophilia B). These disorders are genetically inherited and are not associated with or detected by elevated maternal serum alpha-fetoprotein levels. MSAFP is a screening tool for fetal structural anomalies, not coagulation disorders.