Exhibits

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

Choice A rationale

Asking about the fluid's color (clear, meconium-stained, bloody) provides information about fetal well-being and potential complications (like meconium aspiration), but it is a secondary assessment. While important, it does not supersede the need to immediately assess the most urgent physiological parameter of fetal status, which is the heart rate.

Choice B rationale

The rupture of membranes (water breaking) carries a risk of prolapsed umbilical cord, which can severely compromise fetal oxygenation by compressing the umbilical vessels. Determining the fetal heart rate (FHR) immediately is the priority action to identify signs of fetal distress, such as bradycardia (FHR <110 beats/min), indicating cord compression. The normal FHR range is 110-160 beats/min.

Choice C rationale

Monitoring cervical dilation is necessary to determine the stage and progress of labor. However, in the setting of ruptured membranes, assessing the immediate safety and stability of the fetus takes precedence over checking labor progress. A vaginal exam to check dilation is done after assessing FHR and ruling out immediate emergencies like cord prolapse.

Choice D rationale

Determining the vaginal pH with Nitrazine paper can confirm if the fluid is amniotic fluid (alkaline, pH 7.0-7.5) or urine/vaginal secretions (acidic). While this confirms the rupture of membranes, establishing the status of the fetus by assessing the FHR is the most critical and life-saving priority action to take first to prevent or quickly address fetal hypoxia.

Choice A rationale

Bilirubin monitoring is critical for jaundice due to hemolysis, often seen in ABO incompatibility or cephalohematoma. While Large for Gestational Age (LGA) infants can have polycythemia, hypoglycemia is a more immediate and life-threatening risk that requires priority monitoring in the first hours of life. The normal total bilirubin range is typically less than 5 mg/dL in the first 24 hours.

Choice B rationale

LGA infants are often born to mothers with uncontrolled or gestational diabetes, leading to fetal hyperinsulinism. After birth, the maternal glucose supply is cut off, and the high insulin levels persist, causing a rapid and profound drop in the newborn's blood glucose, hence hypoglycemia is a major concern. The normal newborn glucose range is 40 to 60 mg/dL and should be monitored.

Choice C rationale

White blood cell (WBC) count is primarily monitored to detect neonatal sepsis or infection. While all newborns are at risk, the LGA classification does not inherently place them at a higher, unique risk for infection compared to the immediate metabolic derangement risks like hypoglycemia. The normal WBC count range is 9,000 to 30,000 cells/mm.

Choice D rationale

Arterial Blood Gases (ABGs) are used to assess the newborn's respiratory status and acid-base balance, particularly in respiratory distress syndrome or persistent pulmonary hypertension. While LGA infants can experience birth trauma or meconium aspiration, ABG monitoring is not routine unless significant respiratory symptoms are present.