A nurse is caring for a mother who delivered vaginally 2 hr ago.
Axillary temperature 36.6° C (98.0° F). Heart rate 110/min.
Respiratory rate 24/min.
Oxygen saturation 94%. Select the 4 findings the nurse should report to the provider.

Choice A rationale

Respiratory assessment is crucial postpartum, especially with an elevated respiratory rate. It helps detect any respiratory distress or complications early.

Choice B rationale

Hemoglobin level assessment is essential to identify anemia or excessive blood loss during delivery, which can compromise the mother's health.

Choice C rationale

A heart rate of 110/min is above the normal range and might indicate tachycardia, which requires monitoring and possibly intervention.

Choice D rationale

A constant trickle of blood at the vagina could indicate postpartum hemorrhage, necessitating immediate medical attention.

Choice A rationale

Unstable vital signs in a newborn could be attributed to various causes such as infection, respiratory issues, or cardiovascular problems. It is not directly linked to the absence of phytonadione injection.

Choice B rationale

Low glucose levels in a newborn can result from conditions like prematurity, maternal diabetes, or feeding issues and are not a direct consequence of the absence of a phytonadione injection.

Choice C rationale

Acrocyanosis, a bluish discoloration of the hands and feet, is a common and benign finding in newborns due to immature blood circulation and is not related to the absence of phytonadione.

Choice D rationale

Phytonadione (vitamin K) is essential for blood clotting. Absence of this injection can lead to bleeding issues, such as oozing at circumcision sites, due to vitamin K deficiency bleeding (VKDB).