A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

Weight loss of 3%

Voided one time since birth

Central cyanosis

Apical pulse rate of 156/min

Answer and Explanation

The Correct Answer is C

A. Weight loss of 3%:

Newborns commonly experience weight loss in the first few days of life due to factors such as loss of excess fluid and adjustment to feeding. A weight loss of up to 7-10% in the first week is considered normal. Therefore, a weight loss of 3% alone, while notable, is not typically concerning enough to require immediate intervention. However, it should be monitored closely to ensure that the newborn is receiving adequate nutrition and hydration.

B. Voided one time since birth:

Newborns typically pass urine within the first 24 hours after birth. However, the frequency of voiding can vary, and it is not uncommon for a newborn to void only once in the first 24 hours. While it is important for newborns to void regularly to ensure adequate hydration and renal function, voiding once in the first 24 hours may not necessarily indicate a problem, especially if the newborn is breastfeeding. Therefore, while this finding should be monitored, it may not require immediate intervention.

C. Central cyanosis:

Central cyanosis, characterized by bluish discoloration of the lips, tongue, and mucous membranes, indicates inadequate oxygenation of the blood. It suggests a potential respiratory or cardiac problem that requires immediate evaluation and intervention to ensure adequate oxygenation and prevent complications. Central cyanosis is a concerning finding in newborns and warrants prompt attention from healthcare providers to determine the underlying cause and initiate appropriate treatment.

D. Apical pulse rate of 156/min:

The normal range for a newborn's heart rate is typically 120-160 beats per minute. An apical pulse rate of 156/min falls within this range and is not necessarily indicative of a problem, especially if the newborn is active or crying. While variations in heart rate can occur, a rate of 156/min alone may not be alarming. However, it should be monitored for any changes or trends outside the normal range as part of routine newborn assessment.

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Correct Answer is A

Explanation

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.

Irregular contractions alone are not necessarily concerning. However, if they are not felt by the client, it may indicate decreased fetal movement. Further evaluation is needed to ensure the baby’s well-being.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.

An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period:This finding is reassuring.A reactive NST (with accelerations in FHR) indicates that the baby is healthy and responsive to moveme.

C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.

The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.

D. Three fetal movements perceived by the client in a 20-min testing period.

Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.
Irregular contractions of short duration that are not perceived by the client are not typically concerning during a nonstress test (NST). The primary focus of an NST is to assess fetal heart rate patterns in response to fetal movement and uterine activity. As long as these contractions do not lead to decelerations or other signs of fetal distress, they are not usually indicative of a problem.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.
This is the correct answer. While fetal heart rate accelerations in response to fetal movement are typically reassuring during an NST, an acceleration of 150 beats per minute above the baseline heart rate, lasting 10 seconds, could indicate fetal distress or compromise. Such a significant increase may suggest that the fetus is having difficulty compensating for stress or may be experiencing hypoxia, necessitating further evaluation.

C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.

D. Three fetal movements perceived by the client in a 20-min testing period.
Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.

A. Depressed anterior fontanel B. Epicanthal folds C. Facial asymmetry D. Uneven gluteal skinfolds E. Jitteriness

Correct Answer is C

Explanation

A. Depressed anterior fontanel:

A depressed anterior fontanel is not typically associated with forceps-assisted birth. The fontanelles may become depressed in conditions such as dehydration or if the newborn is in a hypovolemic state, but it is not directly related to forceps use during delivery.

B. Epicanthal folds:

Epicanthal folds are normal anatomical features that are commonly seen in newborns, especially those of certain ethnic backgrounds. They are not indicative of an injury caused by forceps.

C. Facial asymmetry:

Facial asymmetry can occur as a result of forceps application during birth. The forceps' pressure on the baby's face can cause bruising, swelling, or even facial nerve injury, leading to temporary or permanent facial asymmetry.

D. Uneven gluteal skinfolds:

Uneven gluteal skinfolds are not typically associated with forceps-assisted birth. This finding is more commonly seen in conditions such as hip dysplasia or developmental dysplasia of the hip (DDH), and it is not directly related to forceps use during delivery.

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A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

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