A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?

Choice A rationale
If a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage after a cesarean birth, administering a 500 mL lactated Ringer’s IV bolus can help increase the client’s circulating volume and support her hemodynamic stability. This is often the first step in managing postpartum hemorrhage.
Choice B rationale
While evaluating urinary output is an important aspect of postoperative care, it would not directly address the issue of ongoing vaginal bleeding.
Choice C rationale
Applying an ice pack to the incision site can help reduce swelling and provide some pain relief, but it would not address the issue of vaginal bleeding.
Choice D rationale
Replacing the surgical dressing is part of routine postoperative care, but it would not directly address the issue of ongoing vaginal bleeding.

Choice A rationale
An oxygen saturation of 89% in a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet indicates a decline in the newborn’s status. This level of oxygen saturation is below the normal range for a newborn, which is typically above 95%10111213. This could indicate that the newborn is not getting enough oxygen, which could be due to a variety of conditions, including respiratory distress syndrome.
Choice B rationale
Nasal flaring is a sign of respiratory distress in a newborn. However, it is a nonspecific sign and does not necessarily indicate a decline in the newborn’s status. It could be a normal response to the newborn’s efforts to breathe more effectively.
Choice C rationale
Fine crackles can be a sign of a lung condition in a newborn. However, they are a nonspecific sign and do not necessarily indicate a decline in the newborn’s status. They could be a normal finding in a newborn who was born 2 hours ago.
Choice D rationale
An apneic episode less than 15 seconds in a newborn who was born 2 hours ago is not necessarily indicative of a decline in the newborn’s status. Brief periods of apnea (pauses in breathing) are common in newborns and are usually not a cause for concern unless they last longer than 20 seconds or are associated with other signs of distress.