A nurse is caring for a newborn who is 30 minutes old following a spontaneous vaginal birth. The birth parent noted dark brown- greenish amniotic fluid during labor. The newborn was delivered at 42 weeks gestation. Apgar scores were 8 at 1 minute and 9 at 5 minutes.

Exhibits

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? Drag one condition and one client finding to fill in each blank in the following sentence.

The condition that poses the greatest risk to the newborn is

dropdown

due to

dropdown

.

Choice A rationale

Stage I pressure injury is characterized by non-blanchable erythema of intact skin. This means that the skin does not turn white when pressed and is a sign of damage to the underlying

tissues. This stage is often seen in areas of the body that are under constant pressure, such as the heels in a patient who is unable to move.

Choice B rationale

Stage II pressure injury involves partial-thickness loss of skin with exposed dermis. This stage is more severe than stage I and would present with an open wound, which is not described in the question.

Choice C rationale

Stage III pressure injury involves full-thickness loss of skin, in which fatty tissue is visible in the wound. This stage is more severe than both stages I and II and would present with a deeper wound, which is not described in the question.

Choice D rationale

Stage IV pressure injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. This is the most severe stage of pressure injury and would present with a very deep wound exposing underlying structures, which is not described in the question.

Choice A rationale

Petechiae, or small red or purple spots on the skin caused by minor bleeding from broken capillary blood vessels, are an objective finding. They can be seen and evaluated by the nurse during a physical examination.

Choice B rationale

Nausea is a subjective symptom. It is something the patient experiences and reports, but it cannot be directly observed or measured by the nurse.

Choice C rationale

Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective finding. It can be observed by the nurse during a physical examination.

Choice D rationale

Fever is an objective finding. It can be measured by the nurse using a thermometer.