A nurse is caring for a 36-hour-old male newborn who was born at 39 weeks of gestation in the neonatal intensive care unit (NICU). The newborn has been breastfeeding 3 to 4 times per day and has voided once since birth but has not passed meconium stool since birth. The nurse notes that the newborn’s sclera appears yellow.

Exhibits

Which of the following findings should the nurse report to the provider? (Select all that apply.)

Choice A rationale
Chorionic villus sampling (CVS) is a prenatal test that diagnoses chromosomal abnormalities such as Down syndrome, as well as a host of other genetic disorders. While it can determine the sex of the baby, it is not typically used for this purpose.

Choice B rationale
The statement that one cannot have an amniocentesis until they are at least 35 years of age is incorrect. While it is true that amniocentesis is often offered to women over the age of 35 due to an increased risk of chromosomal abnormalities, it can be performed on anyone at risk, regardless of age.
Choice C rationale
Scheduling the procedure for later in the day is not typically how amniocentesis is planned. It is a medical procedure that requires careful planning and preparation. It is usually performed between the 15th and 20th weeks of pregnancy.
Choice D rationale
This is the correct answer. Amniocentesis is a prenatal test that allows doctors to diagnose a range of genetic and chromosomal disorders. It involves taking a small sample of the amniotic fluid that surrounds the baby in the uterus for testing. The procedure can indeed determine if the baby has genetic or congenital disorders.

Choice A rationale: The client’s temperature is 38.3°C (101°F), which is above the normal range (36.5-37.2°C or 97.7-99°F). This could indicate an infection, which is a common postpartum complication. Fever in the postpartum period can be due to endometritis, wound infection, mastitis, or urinary tract infection. Given the client’s report of a burning sensation during urination, a urinary tract infection could be a possibility. This finding requires immediate follow-up.

Choice B rationale: The client’s pulse rate is 110/min, which is above the normal range (60-100/min). This could indicate tachycardia, which can be a response to fever, pain, anxiety, or blood loss. Given the client’s elevated temperature and report of pain, this finding requires immediate follow-up.

Choice C rationale: The client’s respiratory rate is 22/min, which is within the normal range (12-20/min). While it’s slightly elevated, it’s not as concerning as the other findings. However, the nurse should continue to monitor the client’s respiratory rate along with other vital signs.

Choice D rationale: The client’s blood pressure is 140/90 mm Hg, which is higher than the normal range (90-120/60-80 mm Hg). This could indicate hypertension, which can be a complication in the postpartum period. Hypertension can lead to complications such as preeclampsia or eclampsia, which can be life-threatening. This finding requires immediate follow-up.

Choice E rationale: The client has a large amount of lochia rubra. Lochia rubra is normal for the first few days after delivery, but a large amount could indicate postpartum hemorrhage, especially if it’s accompanied by signs of hypovolemia such as tachycardia and hypotension. This finding requires immediate follow-up.

Choice F rationale: The client reports pain as 5 on a scale of 0 to 10. While pain is expected after a vaginal delivery, especially with an episiotomy, it should be manageable with analgesics. If the client’s pain is not well-controlled, it could indicate a complication such as infection or hematoma at the episiotomy site. However, given the information provided, this finding does not require immediate follow-up as much as the others.

Choice G rationale: The client has 3+ peripheral edema in bilateral lower extremities. While some edema is normal during pregnancy and the postpartum period, 3+ edema could indicate a complication such as deep vein thrombosis, especially if it’s accompanied by pain, warmth, or redness. This finding requires immediate follow-up.