A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis. How should the nurse interpret the findings 24 hr later?

Choice A rationale
An oxygen saturation of 89% in a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet indicates a decline in the newborn’s status. This level of oxygen saturation is below the normal range for a newborn, which is typically above 95%10111213. This could indicate that the newborn is not getting enough oxygen, which could be due to a variety of conditions, including respiratory distress syndrome.
Choice B rationale
Nasal flaring is a sign of respiratory distress in a newborn. However, it is a nonspecific sign and does not necessarily indicate a decline in the newborn’s status. It could be a normal response to the newborn’s efforts to breathe more effectively.
Choice C rationale
Fine crackles can be a sign of a lung condition in a newborn. However, they are a nonspecific sign and do not necessarily indicate a decline in the newborn’s status. They could be a normal finding in a newborn who was born 2 hours ago.
Choice D rationale
An apneic episode less than 15 seconds in a newborn who was born 2 hours ago is not necessarily indicative of a decline in the newborn’s status. Brief periods of apnea (pauses in breathing) are common in newborns and are usually not a cause for concern unless they last longer than 20 seconds or are associated with other signs of distress.

Choice A rationale
A WBC count of 11,000/mm is slightly above the normal range (5,000 to 10,000/mm), but it is not uncommon for the WBC count to increase during pregnancy due to physiological changes and increased stress on the body. However, a significantly elevated WBC count could indicate an infection or other medical condition, so it should be monitored closely.
Choice B rationale
A fasting blood glucose level of 180 mg/dL is significantly above the normal range (74 to 106 mg/dL), indicating hyperglycemia. This could be a sign of gestational diabetes, a condition that can develop during pregnancy and cause high blood sugar levels. Gestational diabetes can increase the risk of various pregnancy complications, including preeclampsia, premature birth, and having a baby with a high birth weight. Therefore, this finding should be reported to the provider immediately.
Choice C rationale
A hematocrit level of 37% is within the normal range (37% to 47%), so it would not typically be a cause for concern.
Choice D rationale
A creatinine level of 0.9 mg/dL is within the normal range (0.5 to 1 mg/dL), so it would not typically be a cause for concern.