A nurse is caring for a female client who is primigravida at 30 weeks of gestation in the antepartum unit.

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Choice A rationale

Transient circumoral cyanosis, a bluish discoloration around the mouth, can be a normal finding in the immediate newborn period, especially during periods of crying or temperature instability. It is often related to immature peripheral circulation and typically resolves as the newborn's circulatory system adapts to extrauterine life, without requiring intervention.

Choice B rationale

Transient strabismus, or crossed eyes, is a common and normal finding in newborns due to immature neuromuscular control of eye movements. The newborn's eye muscles are still developing coordination, and occasional misalignment is expected. This usually resolves spontaneously by 3 to 4 months of age as vision matures.

Choice C rationale

Caput succedaneum, a localized soft tissue edema of the scalp, is a common finding in newborns after vaginal birth. It results from pressure on the presenting part of the head during labor. It crosses suture lines and typically resolves within a few days, representing a benign finding that does not require medical intervention.

Choice D rationale

Generalized petechiae, which are small, pinpoint hemorrhages, are an abnormal finding in a 1-hour-old newborn and warrant immediate reporting to the provider. While scattered petechiae over the presenting part may occur with a difficult delivery, generalized petechiae can indicate a coagulation disorder, infection, or other serious underlying pathological condition requiring prompt evaluation and intervention.

Choice A rationale

Epigastric pain in a pregnant client, especially at 33 weeks gestation, can be a symptom of preeclampsia, a serious hypertensive disorder of pregnancy. This pain may indicate hepatic involvement and impending eclampsia, requiring immediate medical evaluation to prevent severe maternal and fetal complications.

Choice B rationale

Leukorrhea, an increase in vaginal discharge, is a common physiological finding during pregnancy due to increased estrogen levels and blood flow to the vaginal area. It is typically thin, white, and odorless, and does not generally require reporting unless accompanied by itching, odor, or color changes.

Choice C rationale

Excessive salivation, or ptyalism, is a common and benign complaint during pregnancy, often attributed to hormonal changes. While bothersome, it does not indicate a pathological condition and is not a finding that requires reporting to the provider.

Choice D rationale

Darkening of the skin on the face, known as chloasma or melasma gravidarum, is a normal physiological change in pregnancy caused by increased melanin production due to hormonal fluctuations. It is a cosmetic issue and not indicative of a medical concern requiring provider notification.