A nurse is caring for a 26-year-old female client who is at 14 weeks of gestation in the antepartum clinic.

Exhibits

Select the 3 findings that are unexpected.

Choice A rationale

While documenting findings is a crucial nursing responsibility, a white blood cell count of 28,000 mm³ in a newborn is significantly elevated. The normal range for a newborn's WBC count is typically between 9,000 to 30,000 mm³, but a value at the higher end or exceeding this range warrants further investigation to rule out infection or other underlying conditions. Simply documenting without further action could delay necessary interventions.

Choice B rationale

A WBC count of 28,000 mm³ in a newborn raises suspicion for neonatal sepsis, a serious bloodstream infection. Unit protocols for a sepsis workup typically involve obtaining blood cultures, a complete blood count with differential, and potentially a lumbar puncture and chest X-ray to identify the source and extent of infection. Prompt initiation of these measures is critical for timely diagnosis and treatment, improving the newborn's prognosis.

Choice C rationale

Taking vital signs is a standard nursing assessment, but in the presence of an abnormal lab value suggestive of a serious condition like sepsis, it is insufficient as the sole action. While changes in vital signs can indicate infection, they may not be present in the early stages. Notifying the provider is necessary, but initiating a sepsis workup concurrently based on unit protocol allows for quicker diagnostic evaluation.

Choice D rationale

A heel stick for a bedside blood glucose reading is indicated for assessing hypoglycemia, a common concern in newborns, particularly those at risk. However, it does not directly address the significantly elevated WBC count. While infection can sometimes affect blood glucose levels, this test would not provide information about the potential underlying cause of the leukocytosis.

Choice A rationale

A dipstick value of 3+ for protein in the urine is a significant indicator of proteinuria, a key diagnostic criterion for preeclampsia. Preeclampsia is characterized by new-onset hypertension and proteinuria or other signs of end-organ damage in a previously normotensive pregnant woman. A 3+ protein level suggests substantial protein spillage into the urine, necessitating immediate attention to assess the severity of preeclampsia and prevent potential complications for both the mother and the fetus. Normal urine protein is typically negative to trace amounts.

Choice B rationale

Pitting pedal edema at the end of the day can be a common finding in pregnancy due to increased blood volume and pressure on the veins in the legs. While edema can be associated with preeclampsia, it is not a primary diagnostic criterion and can occur in normal pregnancies. Therefore, isolated pedal edema without other signs of preeclampsia is less concerning than significant proteinuria.

Choice C rationale

A blood pressure reading of 138/86 mm Hg is mildly elevated and falls within the range for stage 1 hypertension. While hypertension is a diagnostic criterion for preeclampsia, this isolated reading without a significant increase from baseline or other preeclampsia symptoms may not be the most urgent concern compared to significant proteinuria. Preeclampsia diagnosis requires a blood pressure of ≥140 mm Hg systolic or ≥90 mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive woman.

Choice D rationale

A weight gain of 0.5 kg (approximately 1.1 pounds) over two weeks is within the expected range for weight gain during pregnancy. While rapid or excessive weight gain can be a sign of fluid retention associated with preeclampsia, a modest gain of 0.5 kg over two weeks is not a primary indicator of the condition and is less concerning than significant proteinuria.