A nurse is admitting a client who has major depressive disorder. Which of the following actions should the nurse take during the orientation phase of the therapeutic relationship?

A. The newborn's neck is short and surrounded by skin folds: A short neck with skin folds can be a normal variant in some newborns, especially those with subcutaneous fat. While it may warrant observation for potential anomalies, it is not an immediate concern at 24 hours of age.

B. The newborn's glucose level is 50 mg/dL: A glucose level of 50 mg/dL is within the normal range for a full-term newborn. Routine monitoring is sufficient, and this finding does not require urgent reporting.

C. The newborn's sclerae have a yellowish tint: Jaundice appearing within the first 24 hours of life can indicate pathological jaundice, which may result from hemolysis, infection, or metabolic disorders. Early-onset jaundice requires prompt evaluation and intervention to prevent complications such as kernicterus.

D. The newborn has experienced a weight loss of 3% since birth: A weight loss of up to 5–7% in the first few days after birth is considered normal due to fluid shifts. A 3% loss is expected and does not necessitate immediate reporting.

Rationale for correct choices

• oxytocin: The client is term, contracting regularly, and already 3 cm dilated, indicating early active labor progression. Oxytocin may be anticipated to augment labor when contractions are present but not yet efficient. The presence of infection risk (fever, malodorous discharge) also increases the need to progress labor toward delivery.

• nalbuphine: The client reports pain that increases to 8 during contractions, indicating a need for pharmacologic analgesia. Nalbuphine is an opioid analgesic used in labor for moderate to severe pain and is appropriate for intrapartum pain management. It can be anticipated when the client requests stronger pain relief before progression to active labor.

Rationale for incorrect choices

• magnesium sulphate: This medication is used for seizure prophylaxis in preeclampsia or for neuroprotection in preterm labor. The client’s blood pressure is within normal range, and gestation is 38 weeks, so there is no indication for magnesium sulfate.

• misoprostol: Cervical ripening is not required because the cervix is already 3 cm dilated with active contractions. Misoprostol would not be indicated when labor is already progressing, especially in the presence of suspected infection, where accelerating delivery is preferred.

• hydralazine: Hydralazine is an antihypertensive used for severe hypertension in pregnancy. The client’s blood pressure is 128/82 mm Hg, which does not indicate hypertensive management.