A nurse is caring for a preterm infant in the neonatal intensive care unit (NICU) who is at risk for retinopathy of prematurity (ROP). The nurse is educating the parents about ROP and its management.

Which statement by the parents indicates a need for further teaching?

Choice A rationale

A uterine hematoma typically presents with unrelenting pain and may cause signs of hypovolemic shock, which would be evidenced by tachycardia and hypotension, not necessarily a displaced, high fundus as a primary sign. While a Complete Blood Count (CBC) can detect associated anemia (normal hemoglobin is 12-16 g/dL), the immediate priority is addressing the fundus's position.

Choice B rationale

A full or distended urinary bladder pushes the uterus superiorly and laterally, commonly to the right side due to anatomical arrangement, causing it to be palpable above the expected level. This displacement inhibits proper uterine contraction and increases the risk of postpartum hemorrhage. The most appropriate initial intervention is to have the woman void or catheterize her, then reassess the fundus's position and tone.

Choice C rationale

While prolonged positioning can influence physical findings, the bladder's mechanical displacement of the uterus is a more common and clinically significant cause of a fundus displaced high and to the side in the immediate postpartum period. Simply changing position will not resolve the underlying issue of bladder distension, which compromises uterine hemostasis and must be addressed immediately.

Choice D rationale

While the health care provider must be informed of abnormal findings, contacting them is not the first action when a correctable physiological cause is highly suspected. The nurse should first attempt the least invasive intervention, which is addressing the likely full bladder, a common cause of this finding, and then reassess before escalating care. —.

Choice A rationale

Obtaining umbilical cord blood gases provides an objective measure of the acid-base status at birth, reflecting the severity and duration of peri-natal asphyxia; however, an APGAR score of 6 at 5 minutes indicates moderate distress and a need for immediate intervention, not just diagnosis, as the priority. While informative, this step is secondary to stabilization efforts. Normal umbilical arterial pH is 7.25-7.40.

Choice B rationale

An APGAR score of 6 at 5 minutes indicates moderate cardio-respiratory depression, requiring active intervention to prevent further decline and potential injury, thus beginning resuscitative measures is the highest priority. Initial steps often include tactile stimulation and positive pressure ventilation (PPV) if necessary, aiming to rapidly improve vital signs and oxygenation which are the direct parameters affecting the APGAR score.

Choice C rationale

Promoting kangaroo care (skin-to-skin contact) is beneficial for thermoregulation, bonding, and stabilization in stable newborns; however, a score of 6 suggests the infant is not fully stable and requires closer monitoring and potential intervention, making it inappropriate as the initial priority over addressing the compromised respiratory and cardiac status.

Choice D rationale

Initiating IV fluid therapy may be necessary for hypovolemia or to administer medications, but it is not the immediate priority for a newborn with an APGAR score of 6, whose primary needs are establishing effective respiration and circulation. Establishing intravenous access would follow the stabilization of the airway and breathing if necessary. —.