A nurse is caring for a client in labor at 39 weeks of gestation.
Which of the following assessment findings requires follow-up?

Choice A rationale

A newborn who is 26 hours post-delivery and has had no urine output needs immediate attention. Lack of urine output for over 24 hours may indicate dehydration or renal issues. Immediate medical evaluation is required to identify underlying conditions and prevent complications such as acute kidney injury or sepsis.

Choice B rationale

Acrocyanosis, characterized by blueish discoloration of the extremities, is common in newborns during the first 24-48 hours of life and usually resolves on its own. It occurs due to immature blood circulation and is generally not a cause for concern.

Choice C rationale

Failure to pass meconium within the first 24 hours can be a sign of conditions like Hirschsprung's disease or cystic fibrosis, but it is not as immediately concerning as anuria (no urine output). Monitoring and further evaluation are necessary, but it does not require urgent provider notification.

Choice D rationale

A blood glucose level of 50 mg/dL in a newborn is within the lower limit of normal. While it's important to monitor, it does not necessitate immediate provider notification unless it continues to drop or other symptoms arise.

Based on the provided information, here is the completion of the sentence using the options:

The nurse assesses the Non-Stress Test (NST) and documents the results as Non-Reactive. The nurse contacts the provider and reports the NST results. The nurse anticipates an order for a Biophysical Profile.

A Non-Stress Test (NST) is used to monitor the fetal heart rate (FHR) and its response to fetal movements. A reactive NST indicates that there are accelerations in the FHR in response to fetal movements, which is a sign of fetal well-being. A non-reactive NST means that there are no accelerations in the FHR with fetal movements, suggesting that the fetus might not be as active or responding as expected.

In this case, the NST was non-reactive because there were no accelerations in the fetal heart rate. This can be a cause for concern, as it may indicate potential issues with the fetus that need further evaluation. Therefore, the nurse would document the NST as non-reactive and contact the provider for further assessment.

A Biophysical Profile (BPP) is often ordered after a non-reactive NST. The BPP is a more comprehensive test that includes an ultrasound to assess fetal movement, muscle tone, breathing movements, and amniotic fluid volume, in addition to another NST. This helps to provide a clearer picture of the fetus's well-being.