A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following should the nurse recognize as a sign of true labor?

Choice A reason:

Acrocyanosis (choice A) is a common and relatively normal finding in newborns, especially in the first few days of life. It refers to the bluish discoloration of the hands and feet due to peripheral vasoconstriction. Acrocyanosis alone does not necessarily indicate significant difficulty with oxygenation and is usually a transient and benign condition.

Choice B reason:

A respiratory rate of 54 breaths/minute (choice B) is within the normal range for a newborn. The normal respiratory rate for a newborn can range from 30 to 60 breaths per minute. While an abnormal respiratory rate outside this range may be a concern, a rate of 54 breaths/minute is not indicative of significant oxygenation difficulty by itself.

Choice C reason:

Nasal flaring in a newborn is a concerning sign that suggests the baby is experiencing difficulty with oxygenation. When a newborn is having trouble getting enough oxygen, they may instinctively open their nostrils wider (nasal flaring) to increase the airflow into the nose and improve oxygen intake. This is a compensatory mechanism to overcome respiratory distress and is often seen in newborns with respiratory problems. Nasal flaring is an important clinical sign that indicates the baby may be struggling to breathe adequately and requires further evaluation and intervention by the healthcare team.

Choice D reason:

Abdominal breathing (choice D) is a normal breathing pattern in newborns. Newborns predominantly use their diaphragm to breathe, which results in abdominal movements during respiration. This is a normal and expected finding in healthy newborns and does not necessarily suggest oxygenation problems.

The correct answer is: d. Move infant away from blowing fan.

Choice A: Dry the baby after a bath

Drying the baby after a bath is essential to prevent heat loss through evaporation. When a newborn is wet, the water on their skin can evaporate, taking heat away from their body. While this is an important step in maintaining the baby’s temperature, it does not specifically address heat loss through convection.

Choice B: Wrap the baby in warmed blankets

Wrapping the baby in warmed blankets helps prevent heat loss through conduction and radiation. Conduction occurs when the baby comes into contact with a cooler surface, and radiation occurs when the baby loses heat to the surrounding environment. Although this action is beneficial, it does not directly address heat loss through convection.

Choice C: Place the baby in a warmer

Placing the baby in a warmer is an effective way to maintain the baby’s overall body temperature by providing a controlled, warm environment. This action helps prevent heat loss through conduction, radiation, and evaporation. However, it is not the most direct method to prevent heat loss through convection.

Choice D: Move infant away from blowing fan

Moving the infant away from a blowing fan directly addresses and prevents heat loss due to air movement, which is a key factor in convection. Convection occurs when air currents carry heat away from the baby’s body. By moving the baby away from the fan, the nurse can effectively reduce heat loss through this mechanism.