A nurse is assessing a full-term newborn upon admission t (2024)

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Single palmar creases

Rust-stained urine

Subconjunctival hemorrhage

Transient circumoral cyanosis

Answer and Explanation

The Correct Answer is B

This is the clinical finding that the nurse should report to the provider following this medication. Rust- stained urine is a sign of urate crystals in the newborn's urine, which can indicate dehydration or inadequate ﬂuid intake⁷. Urate crystals are made of uric acid, a waste product that is excreted in urine. They can cause a pink or red-orange stain in the diaper, which can be mistaken for blood⁷. Urate crystals are common in the first few days after birth, especially in breastfed babies who may not be getting enough milk⁷. However, if they persist or are accompanied by other signs of dehydration, such as decreased saliva, dry lips, lethargy, or reduced wet diapers, they should be reported to the provider⁷. The nurse should also monitor the baby's weight and feeding paterns and encourage the mother to breastfeed frequently or oﬀer formula if needed.

The other options are not correct because they are not signs of an adverse eﬀect from butorphanol. Let me
explain why:
a) Single palmar creases
Single palmar creases are single lines that cross the palm of the hand, formed by the fusion of two normal creases¹. They are present in about 1 out of 30 people, more often in males than females¹. They are usually harmless and do not aﬀect the function of the hand¹. However, they may be associated with some genetic or developmental disorders, such as Down syndrome, fetal alcohol syndrome, or Aarskog syndrome¹³.
Therefore, the nurse should examine the baby for any other physical anomalies or signs of chromosomal abnormalities and refer them to a geneticist if needed.
c) Subconjunctival hemorrhage
Subconjunctival hemorrhage is a burst blood vessel in the white of the eye, causing a bright red spot on the eye[^10^]. It is usually painless and does not aﬀect vision[^10^]. It is very common in newborns after a traumatic delivery, especially when forceps or vacuum extraction are used[^10^] ¹²¹⁴. It is usually benign and resolves on its own within 1-2 weeks[^10^]. The nurse should reassure the parents and monitor the baby for any signs of infection or bleeding disorders.
d) Transient circumoral cyanosis
Transient circumoral cyanosis is a blue discoloration around the mouth only, caused by low levels of oxygen in the blood vessels near the skin surface¹⁵. It is often seen in infants during the first few days after birth or when they are exposed to cold temperatures¹⁵. It is usually normal and harmless and goes away once they warm up¹⁵. However, if the cyanosis aﬀects other parts of the face or body, such as the lips or tongue, it could be a sign of a serious lung or heart problem and should be reported immediately¹⁵. The nurse should check the baby's oxygen saturation, heart rate, and respiratory rate and look for any signs of distress.

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Correct Answer is D

Explanation

Heart rate is one of the vital signs that reﬂects the health and well-being of a newborn. It is measured by counting the number of heart beats per minute, either by listening to the chest with a stethoscope or by feeling the pulse at the wrist, elbow, or groin. Heart rate can vary depending on the newborn's activity level, temperature, and emotional state¹.
The normal range for heart rate in full-term newborns is 120 to 160 beats per minute. The heart rate may be slightly higher or lower depending on the newborn's age, weight, and gestational age. For example, premature newborns may have a higher heart rate than term newborns, and heavier newborns may have a lower heart rate than lighter newborns¹².
A heart rate that is too high (tachycardia) or too low (bradycardia) can indicate a problem with the newborn's heart function, oxygenation, or circulation. Some of the possible causes of abnormal heart rate in newborns are:

- Congenital heart defects: structural abnormalities of the heart that are present at birth and aﬀect the blood ﬂow through the heart and the body. They can cause cyanosis (bluish skin color), murmur (abnormal heart sound), poor feeding, or failure to thrive¹³.
- Arrhythmias: irregular or abnormal heart rhythms that can aﬀect the electrical impulses that control the heartbeat. They can cause palpitations (feeling of skipped or extra beats), dizziness, fainting, or cardiac arrest¹³.
- Hypoxia: lack of oxygen in the blood or tissues that can aﬀect the brain and other organs. It can be caused by respiratory distress, anemia, infection, or birth asphyxia. It can cause bradycardia, apnea (pauses in breathing), seizures, or coma¹⁴.
- Hypothermia: low body temperature that can aﬀect the metabolism and organ function. It can be caused by exposure to cold environment, infection, or prematurity. It can cause bradycardia, lethargy, poor feeding, or hypoglycemia (low blood sugar)¹⁴.
- Sepsis: severe infection that can aﬀect the whole body and cause inﬂammation and organ damage. It can be caused by bacteria, viruses, fungi, or parasites that enter the bloodstream from the mother, the umbilical cord, or the environment. It can cause tachycardia, fever, chills, poor feeding, or shock¹⁴.
Therefore, the nurse should report a heart rate of 72/min to the provider as an abnormal finding and monitor the newborn for any other signs of distress or illness. The provider may order further tests or treatments to determine the cause and severity of the low heart rate and prevent any complications.

Correct Answer is A

Explanation

A client who is in labor and reports an urge to have a bowel movement during contractions may be experiencing the transition phase of labor, which is the last and most intense part of the first stage of labor¹². The transition phase occurs when the cervix dilates from 8 to 10 cm and the baby descends into the birth canal¹². The pressure of the baby's head on the rectum can cause a sensation of needing to defecate¹². The transition phase can last from 15 minutes to an hour or more, and it can be accompanied by other signs, such as strong, regular, and painful contractions lasting 60 to 90 seconds; increased bloody show; nausea and vomiting; shaking and shivering; and emotional changes such as irritability, anxiety, or excitement¹²³.
The nurse should reassess the client who reports an urge to have a bowel movement during contractions because this may indicate that the client is close to delivering the baby and needs to be prepared for the second stage of labor, which involves pushing and giving birth¹². The nurse should check the client's cervical dilation, fetal heart rate, and maternal vital signs, and notify the provider if the client is fully dilated or shows signs of fetal or maternal distress¹². The nurse should also support the client's coping strategies, such as breathing techniques, relaxation methods, or pain relief options, and encourage the client not to push until instructed by the provider¹².

b) A sense of excitement and warm, ﬂushed skin are not signs that require reassessment by the nurse. These are normal emotional and physiological responses to labor that reﬂect increased adrenaline levels and blood ﬂow¹⁴. They do not indicate any complications or imminent delivery.
c) Progressive sacral discomfort during contractions is not a sign that requires reassessment by the nurse. This is a common symptom of labor that results from the pressure of the baby's head on the sacrum and nerves in the lower back¹⁴. It does not indicate any problems or imminent delivery.
d) Intense contractions lasting 45 to 60 seconds are not signs that require reassessment by the nurse. These are typical characteristics of active labor contractions, which occur when the cervix dilates from 4 to 8 cm¹⁴. They do not indicate any complications or imminent delivery.

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