Exhibits

The nurse is assessing the client 15 minutes later. How should the nurse interpret the following findings?

Choice A rationale

Soft grunting noises during expiration are a sign of mild to moderate respiratory distress in a newborn. Grunting is the newborn's attempt to keep the alveoli open by increasing Positive End-Expiratory Pressure (PEEP), suggesting decreased lung compliance or insufficient surfactant. This finding requires immediate notification of the provider for evaluation and potential intervention.

Choice B rationale

A positive Babinski reflex, which involves the great toe dorsiflexing and the other toes fanning out upon stroking the sole of the foot, is a normal neurological finding in a newborn and infant. This reflex persists until about 1 to 2 years of age as the central nervous system matures, and therefore does not require reporting.

Choice C rationale

Acrocyanosis, which is pale blue hands and feet with pinkish trunk and mucous membranes, is a common and normal finding in a newborn during the first 24 to 48 hours after birth due to immature peripheral circulation and cold exposure. This peripheral vasoconstriction resolves spontaneously and is not typically reported unless accompanied by central cyanosis.

Choice D rationale

Blood-tinged discharge from the vagina, often called pseudomenstruation, is a normal, transient finding in female newborns. It is caused by the withdrawal of maternal estrogen hormones following birth, leading to a minor sloughing of the uterine endometrium, and does not indicate a pathological condition requiring immediate reporting.

🧾 Explanation

1. Moderate lochia rubra
   • Normal up to 1–2 weeks postpartum. Not related to mastitis.
2. Temperature 38.4°C
   • Still febrile after 24 hrs of antibiotics → infection not yet controlled.
3. Purulent nipple discharge
   • New finding. Indicates possible breast abscess or worsening mastitis.
4. Hemoglobin 12 g/dL
   • Stable and within normal range. Not relevant to mastitis progression.
5. WBC 35,000/mm³
   • Increased from 28,000 → worsening systemic inflammatory response.
6. Decreased pain
   • Symptomatically better, but this may reflect partial relief from antibiotics/analgesics rather than full resolution. Still, it’s a positive sign.

Summary:

• Improving: Pain relief.
• Unrelated: Lochia rubra, hemoglobin.
• Worsening: Persistent fever, purulent nipple discharge, rising WBC.

This mixed picture suggests partial response but possible complication (breast abscess). The nurse should notify the provider promptly, anticipate breast ultrasound to rule out abscess, and continue close monitoring.