A nurse is caring for a client who is in active labor. The nurse should notify the provider for which of the following findings?

A. The catheter should be picked up carefully, but the length from the tip is less important than maintaining sterility.

B. Cleansing the area is typically done with a single clean swab in a circular motion from the urethral meatus outward.

C. The correct technique for cleaning the penis is a circular motion from the urethra outward, not side-to-side.

D. Lifting the penis perpendicular to the body helps straighten the urethra, making catheter insertion easier and reducing the risk of injury.

Rationale:

Keep neonate prone: Contraindicated. Placing the neonate in a prone position may increase the risk of aspiration, especially in the context of respiratory distress or abdominal issues, so it is generally avoided unless clinically necessary in a controlled environment.

Administer total parenteral nutrition (TPN): Anticipated. TPN may be required if the neonate is unable to tolerate oral or enteral feeding due to gastrointestinal distress, as seen with abdominal distention and blood in stool.

Encourage parent bonding: Anticipated. Parent bonding is important for the emotional and developmental support of the neonate, even in critical care settings. However, it must be done in a manner that does not compromise the neonate’s health (e.g., ensuring sterile technique).

Obtain an arterial blood gas: Anticipated. Given the neonate's respiratory status and potential infection, obtaining an ABG is appropriate to assess acid-base balance and oxygenation status.

Attach OG tube to low intermittent suction: Anticipated. Suctioning through the OG tube may be necessary if the neonate has signs of gastrointestinal distress, such as abdominal distention, to remove excess gastric contents or air.

Repeat abdominal x-ray every 24 hr: Contraindicated. Repeating an x-ray every 24 hours may not be necessary unless there are significant changes in the neonate’s condition. Continuous monitoring with clinical assessments is typically prioritized.

Obtain a CBC and blood culture: Anticipated. Given the neonate's lethargy, hypotonia, and other concerning signs, a CBC and blood cultures are necessary to evaluate for infection, which is a common complication in critically ill neonates.

Administer IV antibiotics: Anticipated. Administration of IV antibiotics is essential, especially with signs of possible infection such as lethargy, distended abdomen, and blood in the stool, which may indicate sepsis or necrotizing enterocolitis.