A nurse is caring for a term newborn who is 48 hr old

Exhibits

The nurse 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, a sign of potential improvement, or a sign of potential worsening condition.

A. Epicanthal folds: Epicanthal folds are the skin folds of the upper eyelid covering the inner corner of the eye. These folds are a normal anatomical variation and are not typically related to forceps-assisted births.

B. Depressed anterior fontanel: A depressed fontanel (the soft spot on a baby's head) might indicate dehydration or a potential concern but is not directly associated with forceps use during birth.

C. Facial asymmetry

Forceps-assisted births involve the use of forceps to aid in the delivery of the baby's head. Facial asymmetry can occur as a result of the pressure applied by the forceps during the birth process. This pressure might cause temporary facial bruising or swelling, leading to an asymmetrical appearance, particularly in the immediate post-birth assessment.

D. Uneven gluteal skinfolds: Uneven gluteal skinfolds, which refer to asymmetry in the skinfolds of the buttocks, are not typically linked to forceps use during delivery. This finding might be a normal variation or could indicate other unrelated conditions.

A. Three fetal movements perceived by the client in a 20-min testing period: Perceiving fetal movements during the testing period is a positive finding and indicative of fetal well-being.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period: This is considered a reassuring result in an NST, showing an appropriate acceleration in the fetal heart rate in response to fetal movement, which is a normal and positive finding.

C. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client

During a nonstress test (NST), the presence of uterine contractions can sometimes interfere with the interpretation of fetal heart rate (FHR) patterns. If contractions occur but are not felt by the client, it can affect the accuracy of the test. Therefore, irregular contractions that are not felt by the client may prompt the need for further evaluation or testing to ensure accurate assessment of fetal well-being.

D. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period: Absence of late decelerations during uterine contractions is also a reassuring finding, indicating that the baby is tolerating the stress of contractions well.