1. A nurse is caring for a newborn immediately following birth.

Exhibit 1

Medical History

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor

Exhibit 2

Vital Signs

Apgar:

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Exhibit 3

Medications

Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth

Exhibit 4

Laboratory Findings

WBC count 15,000mm (9,000 to 30,000/mm)

Hgb 19 g/dl (15 to 24 g/dL)

HCt 57% (44% to 70%)

Blood glucose 44 mg/dl (40 to 60 mg/dL)

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or indication that the client's condition is worsening

• Heart rate 110/min
  Correct (requires follow-up) – A heart rate of 110/min is elevated, which could indicate dehydration or other physiological stress, such as hyperemesis gravidarum.

• Blood pressure 104/66 mm Hg
  Wrong (does not require follow-up) – This blood pressure is within normal limits, particularly in pregnancy, where slight decreases in blood pressure are common.

• Hemoglobin 10.2 g/dL
  Correct (requires follow-up) – This is lower than the normal range (11 to 16 g/dL) and indicates mild anemia, which should be monitored during pregnancy.

• Potassium 3.3 mEq/L
  Correct (requires follow-up) – This potassium level is below the normal range (3.5 to 5 mEq/L), indicating hypokalemia, likely due to vomiting. Hypokalemia needs correction as it can cause complications.

• BUN 28 mg/dL
  Correct (requires follow-up) – Blood urea nitrogen (BUN) is elevated (normal range 10 to 20 mg/dL), which could indicate dehydration, a concern especially with vomiting and reduced intake.

• Urine specific gravity 1.045
  Correct (requires follow-up) – This is higher than the normal range (1.005 to 1.03), suggesting concentrated urine and potential dehydration.

• Decreased skin turgor
  Correct (requires follow-up) – Decreased skin turgor is a physical sign of dehydration and should be addressed, especially considering the client's vomiting.

• WBC count 7,500/mm3
  Wrong (does not require follow-up) – The WBC count is within the normal range (5,000 to 10,000/mm3), so it does not indicate an infection or other abnormalities.

• Client reports vomiting several times a day over the last 2 weeks
  Correct (requires follow-up) – Persistent vomiting over this time period is concerning for hyperemesis gravidarum and could lead to complications such as dehydration and electrolyte imbalances.

• Urine color dark amber
  Correct (requires follow-up) – Dark amber urine could be a sign of dehydration, especially in combination with an elevated urine specific gravity.

A. "Hypnosis can be beneficial if you practiced it during the prenatal period":

This statement is accurate. Hypnosis techniques for pain management during labor can be more effective if the client has practiced and familiarized themselves with the techniques during the prenatal period. Regular practice can help the client achieve a deeper state of relaxation and better utilize hypnosis for pain control during labor.

B. "Synchronized breathing will be required during hypnosis":

While synchronized breathing techniques can be part of hypnosis practice, it is not necessarily a requirement for hypnosis to be effective for pain management during labor. Different hypnosis techniques may focus on various aspects such as visualization, deep relaxation, or suggestion to manage pain.

C. "Focusing on controlling body functions will be helpful during hypnosis":

While focusing on controlling body functions, such as breathing or muscle tension, can be part of hypnosis techniques, it is not the only focus. Hypnosis for pain management during labor often involves guiding the mind to a state of deep relaxation and altering perceptions of pain rather than directly controlling body functions.