A nurse is assisting in the initiation of phototherapy.
Which nursing action is indicated for the newborn?

Choice A rationale

A respiratory rate (RR) of 24/min in a 4-hour-old newborn is below the normal range, which is typically 30 to 60 breaths per minute. A sustained low respiratory rate, especially in a neonate, can indicate respiratory depression, central nervous system depression, or impending respiratory failure, necessitating immediate reporting to the healthcare provider for further evaluation and intervention to ensure adequate oxygenation and ventilation.

Choice B rationale

A blood pressure (BP) of 82/44 mm Hg is generally within the expected normal range for a full-term newborn, with typical systolic values ranging from 60 to 90 mm Hg and diastolic values from 30 to 60 mm Hg. This finding reflects adequate cardiac output and vascular tone; therefore, it is considered a reassuring and expected physiological finding that does not require immediate notification of the provider.

Choice C rationale

A temperature of 37.2° C (99° F) falls within the normal range for a newborn, which is typically between 36.5° C and 37.5° C (97.7° F and 99.5° F). This temperature indicates effective thermoregulation and is an expected finding, as newborns maintain a slightly higher core temperature than older children and adults.

Choice D rationale

A heart rate (HR) of 150/min is within the normal resting heart rate range for a newborn, which is typically 110 to 160 beats per minute. Sinus tachycardia can be normal with crying or activity, and 150/min is an expected and acceptable finding that indicates a healthy circulatory status.

Choice A rationale

Placing tennis balls on the sacral area and leaning against them is a technique generally used to apply counter-pressure to the lower back. This method is effective for relieving the discomfort of back labor, where the fetal occiput is pressing on the mother's sacrum. It is a mechanical pain relief strategy, not acupressure, which involves applying pressure to specific anatomical points (meridians) to stimulate the body's natural pain-relieving mechanisms, such as endorphin release.

Choice B rationale

The instruction to "recognize specific signals, respond, and relax" aligns with the basic principles of acupressure use during labor. Acupressure is an intervention where the client applies sustained pressure to specific acupuncture points, which requires paying attention to the onset and intensity of contractions (signals) to effectively time the pressure application (respond) and then concentrating on relaxation techniques. This mind-body connection enhances the pain-relieving effect by stimulating endorphin release and reducing muscular tension during labor contractions.

Choice C rationale

Using light, rhythmic stroking on the abdomen while breathing is a comfort measure known as effleurage. This technique is often taught as part of prepared childbirth methods, like Lamaze, to distract the woman from the pain of contractions through cutaneous stimulation. Effleurage is a form of light touch massage, fundamentally different from acupressure, which requires deep, sustained pressure on specific points to achieve its therapeutic effect, such as modulating pain perception.

Choice D rationale

Hydrotherapy, or immersing oneself in warm water, is a widely used non-pharmacological comfort measure in labor. The warm water promotes muscle relaxation, reduces the perception of pain through buoyancy and warmth, and can increase the production of natural pain relievers (endorphins). This method provides systemic relief and is entirely distinct from acupressure, which relies on targeted, localized pressure at specific anatomical points to manage labor discomfort.