The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best?

Choice a) Headaches is correct because this is a condition that can indicate a serious problem in the postpartum period and may require careful medical assessment. Headaches are common in the first few weeks after giving birth, but they can also be a sign of complications such as preeclampsia, eclampsia, cerebral venous thrombosis, meningitis, or aneurysm. Preeclampsia and eclampsia are conditions that cause high blood pressure, proteinuria, and seizures in pregnant or postpartum women. Cerebral venous thrombosis is a blood clot in the brain that can cause stroke-like symptoms. Meningitis is an infection of the membranes that cover the brain and spinal cord. Aneurysm is a bulge or rupture in a blood vessel that can cause bleeding in the brain. These conditions can be life-threatening and require immediate treatment. Therefore, women who experience severe, persistent, or unusual headaches in the postpartum period should seek medical attention as soon as possible.

Choice b) Varicosities of the legs is incorrect because this is not a condition that usually requires careful medical assessment in the postpartum period. Varicosities are enlarged or swollen veins that appear blue or purple under the skin. They are common in pregnancy due to increased blood volume, hormonal changes, and pressure from the growing uterus. They usually improve after delivery, but may persist or worsen in some women. Varicosities are usually harmless and do not cause any symptoms, but they may cause cosmetic concerns, discomfort, itching, or bleeding. They can also increase the risk of superficial thrombophlebitis, which is inflammation of a vein near the skin surface. However, these complications are rare and mild, and can be managed with conservative measures such as compression stockings, elevation of the legs, exercise, and painkillers. Therefore, women who have varicosities of the legs in the postpartum period do not need to worry too much, unless they have signs of infection or deep vein thrombosis, which is a more serious condition that involves a blood clot in a deep vein that can travel to the lungs and cause pulmonary embolism.

Choice c) Carpal tunnel syndrome is incorrect because this is not a condition that typically requires careful medical assessment in the postpartum period. Carpal tunnel syndrome is a condition that causes numbness, tingling, pain, or weakness in the hand and wrist due to compression of the median nerve that runs through a narrow passage called the carpal tunnel. It can occur in pregnancy due to fluid retention, hormonal changes, or repetitive movements. It usually resolves after delivery, but may persist or recur in some women. Carpal tunnel syndrome is usually mild and does not cause any serious complications, but it may interfere with daily activities or quality of life. It can be treated with conservative measures such as splinting, icing, massage, stretching, or painkillers. In severe cases, surgery may be needed to release the pressure on the nerve. Therefore, women who have carpal tunnel syndrome in the postpartum period do not need to seek medical attention urgently, unless they have signs of nerve damage or infection.

Choice d) Periodic numbness and tingling of the fingers is incorrect because this is not a condition that generally requires careful medical assessment in the postpartum period. Periodic numbness and tingling of the fingers can be caused by various factors such as cold exposure, poor circulation, nerve compression, vitamin deficiency, or anxiety.

It can also occur in pregnancy due to fluid retention or hormonal changes. It usually goes away after delivery, but may linger or come back in some women. Periodic numbness and tingling of the fingers is usually harmless and does not indicate any serious problem, but it may cause discomfort or annoyance. It can be relieved with simple measures such as warming up, moving around, shaking out the hands, taking supplements, or relaxing. Therefore, women who experience periodic numbness and tingling of the fingers in the postpartum period do not need to worry too much, unless they have signs of infection or neurological disorder.

Choice A) Newborns are abdominal breathers is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a characteristic of how newborns breathe. Abdominal breathing means that the diaphragm and the abdominal muscles are the main muscles used for breathing, rather than the chest muscles. Newborns are abdominal breathers because their chest wall is more compliant and less stable than adults, and their intercostal muscles are not fully developed. Abdominal breathing does not affect the accuracy or duration of measuring the respiratory rate, as long as the abdomen is visible and palpable. Therefore, this response is irrelevant and inaccurate.

Choice B) Activity will increase the respiratory rate is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a factor that can influence the respiratory rate. Activity means any physical or mental exertion that requires more oxygen and energy from the body. Activity can increase the respiratory rate, as well as the heart rate and blood pressure, to meet the increased oxygen demand and carbon dioxide removal. However, activity does not affect the accuracy or duration of measuring the respiratory rate, as long as the newborn is calm and resting during the measurement. Therefore, this response is irrelevant and inaccurate.

Choice C) The rate and rhythm of breath are irregular in newborns is correct because this is a reason why the respiratory rate should be counted for a complete minute. The rate and rhythm of breath refer to how fast and how regularly one breathes. Newborns have an irregular rate and rhythm of breath, which means that they breathe at different speeds and intervals, sometimes pausing for a few seconds between breaths. This is normal and harmless for newborns, as long as they do not stop breathing for more than 20 seconds or show signs of distress. However, it can make it difficult to measure the respiratory rate accurately, as counting for a shorter period may not reflect the true average rate. Therefore, counting for a complete minute can ensure a more reliable measurement. Therefore, this response is clear and accurate.

Choice D) Newborns do not expand their lungs fully with each respiration is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a feature of how newborns breathe.

Lung expansion means how much air one inhales and exhales with each breath. Newborns do not expand their lungs fully with each respiration, because they have smaller lung volumes and capacities than adults, and they breathe more shallowly and rapidly. However, lung expansion does not affect the accuracy or duration of measuring the respiratory rate, as long as the chest or abdomen movement is visible and palpable. Therefore, this response is irrelevant and inaccurate.