A nurse is assessing a postmature infant.
Which of the following findings would the nurse expect? (Select all that apply.)

Choice A rationale

A positive rubella serum antibody titer indicates immunity to rubella infection, which is protective during pregnancy. It is not an abnormal finding and does not require immediate reporting. Rubella immunity is important to prevent congenital rubella syndrome in the fetus, a severe condition causing defects such as deafness or cardiac anomalies.

Choice B rationale

Blood pressure of 144/94 mmHg is elevated and indicates gestational hypertension, which could progress to preeclampsia if not managed. Preeclampsia can lead to complications such as eclampsia, placental abruption, or maternal and fetal mortality. Normal blood pressure during pregnancy is less than 140/90 mmHg, making this finding critical to report.

Choice C rationale

Copious leukorrhea is a common physiological change in pregnancy due to increased estrogen levels and vascularity. It is usually benign and protective, preventing infections by maintaining a mildly acidic environment in the vagina. This finding does not warrant immediate concern unless associated with infection symptoms.

Choice D rationale

An O-negative blood type requires administration of Rh immunoglobulin to prevent Rh isoimmunization, but this is routinely managed in pregnancy. It is not an urgent issue unless there are concerns about fetomaternal hemorrhage or alloimmunization, which could harm an Rh-positive fetus.

Choice A rationale

Reporting to a child abuse hotline is a priority intervention when there is a suspicion of non-accidental trauma, such as a spiral fracture in a non-ambulatory infant. Spiral fractures are highly indicative of twisting injuries, which are unlikely to result from a fall and suggest possible abuse.

Choice B rationale

Educating the mother on safety is an important intervention for accidental injuries but does not address the immediate concern of potential abuse. The focus should be on investigating the cause of the injury to ensure the child’s safety.

Choice C rationale

Informing the mother to call the nurse for all diaper changes is not relevant to investigating potential abuse. This action fails to prioritize the safety and protection of the child in cases where abuse is suspected.

Choice D rationale

Completing the Morse Fall Scale assesses fall risk and is not appropriate for investigating the etiology of the injury. It does not address the immediate need to ensure the child’s safety or initiate an investigation into possible abuse.