A nurse is caring for a 32-year-old female client in the postpartum unit who had a cesarean birth due to preeclampsia. The client has been prescribed misoprostol.

Exhibits

The nurse is assessing the client 1 hour later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.

Choice A rationale: A positive Coombs test indicates that the newborn has antibodies against his own red blood cells, which can lead to hemolytic disease of the newborn. This condition can cause severe anemia and jaundice, which can lead to complications such as kernicterus if not treated promptly.

Choice B rationale: The newborn’s glucose level is within the normal range (40 to 60 mg/dL), so this finding does not require immediate follow-up.

Choice C rationale: The yellow color of the sclera indicates jaundice, which can be a sign of hyperbilirubinemia. This condition can lead to complications such as kernicterus if bilirubin levels become too high.

Choice D rationale: The absence of meconium stool in a 36-hour-old newborn is unusual, as most newborns pass meconium within the first 24 to 48 hours after birth. This could indicate a problem such as meconium ileus or Hirschsprung disease, which would require further evaluation.

Choice E rationale: The head assessment finding of caput succedaneum is a common and typically harmless condition in newborns caused by pressure on the head during delivery. It does not require immediate follow-up.

Choice F rationale: The newborn’s heart rate is slightly elevated (normal range for a newborn is 120-160 beats per minute). This could be a response to factors such as fever, pain, or distress, and should be reported to the provider.

Choice G rationale: The newborn’s respiratory rate is also elevated (normal range for a newborn is 30-60 breaths per minute). This could be a sign of respiratory distress and should be reported to the provider.

Choice H rationale: Dry mucous membranes can be a sign of dehydration, which can occur if the newborn is not feeding well or is losing too much fluid, for example, through excessive sweating due to fever. This should be reported to the provider.

• Urine pH 5.0: This is an improvement as the pH has increased from 4.4, moving closer to the normal range (4.6 to 8).
• Urine specific gravity 1.050: This is a sign of potential worsening as the specific gravity has increased from 1.040, indicating possible dehydration.
• 3+ ketones: This is a sign of potential worsening as the presence of ketones has increased from 2+, indicating the body is breaking down fat for energy due to insufficient glucose.
• Urinary output 40 mL/hr: This is an improvement as the urinary output has increased from 20 mL/hr, indicating better hydration.
• Heart rate 130/min: This is a sign of potential worsening as the heart rate has increased from 128/min, possibly due to dehydration.
• WBC count 10,000/mmt: This is unrelated to the diagnosis as it’s within the normal range (5,000 to 10,000/mm³) and doesn’t directly relate to the client’s symptoms of vomiting and dehydration.