When caring for a client with pre-eclampsia, which laboratory result should the nurse report to the physician immediately?

Choice A rationale

While documenting findings is a crucial nursing responsibility, a white blood cell count of 28,000 mm³ in a newborn is significantly elevated. The normal range for a newborn's WBC count is typically between 9,000 to 30,000 mm³, but a value at the higher end or exceeding this range warrants further investigation to rule out infection or other underlying conditions. Simply documenting without further action could delay necessary interventions.

Choice B rationale

A WBC count of 28,000 mm³ in a newborn raises suspicion for neonatal sepsis, a serious bloodstream infection. Unit protocols for a sepsis workup typically involve obtaining blood cultures, a complete blood count with differential, and potentially a lumbar puncture and chest X-ray to identify the source and extent of infection. Prompt initiation of these measures is critical for timely diagnosis and treatment, improving the newborn's prognosis.

Choice C rationale

Taking vital signs is a standard nursing assessment, but in the presence of an abnormal lab value suggestive of a serious condition like sepsis, it is insufficient as the sole action. While changes in vital signs can indicate infection, they may not be present in the early stages. Notifying the provider is necessary, but initiating a sepsis workup concurrently based on unit protocol allows for quicker diagnostic evaluation.

Choice D rationale

A heel stick for a bedside blood glucose reading is indicated for assessing hypoglycemia, a common concern in newborns, particularly those at risk. However, it does not directly address the significantly elevated WBC count. While infection can sometimes affect blood glucose levels, this test would not provide information about the potential underlying cause of the leukocytosis.

Choice A rationale

Monitoring uterine contractions is important during labor, but in the context of late pregnancy bleeding, the immediate priority is to assess the well-being of both the mother and the fetus. Contractions may or may not be present at this stage.

Choice B rationale

Placing clean disposable pads is a reasonable action to manage bleeding and assess its characteristics. However, it does not address the immediate need to evaluate the maternal and fetal status, which is critical in a bleeding episode during late pregnancy.

Choice C rationale

Assessing fetal heart rate (FHR) is crucial to determine fetal well-being in the presence of bleeding. Maternal vital signs (blood pressure, heart rate, respiration) are equally important to evaluate the mother's hemodynamic stability. Bleeding in late pregnancy can compromise both maternal and fetal oxygenation and perfusion, making this assessment the highest priority. Normal maternal heart rate is typically 60-100 beats per minute, and normal maternal blood pressure is typically 90/60 mmHg to 120/80 mmHg. The normal fetal heart rate range is 110-160 beats per minute.

Choice D rationale

Performing a venipuncture for hemoglobin and hematocrit levels will provide information about the extent of blood loss and the mother's oxygen-carrying capacity. While this is an important assessment, it is not the immediate priority compared to evaluating the fetal heart rate and maternal vital signs, which provide real-time information about their current status. Normal hemoglobin for pregnant women typically ranges from 10.5 to 14 g/dL in the first and third trimesters and slightly lower in the second trimester due to hemodilution. Normal hematocrit for pregnant women typically ranges from 32% to 42%.