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

Physical Examination

• High-pitched cry
• Mild tremors when disturbed Increased muscle tone Sneezing six times within 1 hr Excessive sucking
• Color: Consistent with genetic background Excoriation of the chin
• Watery stools Projectile vomiting
• Hyperactive Moro reflex

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

A. Peripheral edema 2+ bilateral lower extremities - Peripheral edema is common postpartum and does not typically require immediate follow-up unless it is associated with other concerning signs or symptoms.
B. Blood pressure 136/6 mm Hg - The blood pressure provided appears to be incorrect, as the diastolic pressure is unusually low. However, given the options provided, blood pressure is not explicitly mentioned in the scenario as a critical factor requiring immediate follow-up.
C. Lateral deviation of the uterus - Lateral deviation of the uterus suggests uterine atony, a potential complication of postpartum hemorrhage, requiring immediate follow-up and intervention to prevent further complications.
D. Pain rating of 3 on a scale of 0 to 10 - While increased pain should be addressed, it does not necessarily indicate an emergency situation requiring immediate follow-up compared to other findings such as uterine deviation or excessive bleeding.
E. Deep tendon reflexes 1+ - This finding is within normal limits and does not require immediate follow-up.
F. Breasts soft - Soft breasts are expected in the postpartum period and do not typically require immediate follow-up unless associated with other concerning signs or symptoms.

G. Large amount of lochia rubra - A large amount of bright red lochia could indicate postpartum hemorrhage, necessitating immediate follow-up and intervention to prevent further complications.
H. Uterine tone soft - Soft uterine tone suggests uterine atony, which is a potential complication requiring immediate follow-up and intervention to prevent excessive bleeding.

Platelet count 90,000/mm3: Sign of Potential Worsening Condition - A decreased platelet count may indicate worsening preeclampsia and a risk of developing HELLP syndrome or thrombocytopenia.

Hematuria: Sign of Potential Worsening Condition - Hematuria suggests potential kidney involvement, which is a serious complication of preeclampsia, indicating a worsening condition. Positive clonus: Sign of Potential Worsening Condition - Positive clonus is a neurological sign associated with preeclampsia and indicates hyperreflexia, which can lead to seizures if untreated. Proteinuria 2+: Sign of Potential Worsening Condition - Increased proteinuria indicates ongoing kidney dysfunction, which is a worsening sign of preeclampsia.

Leukorrhea: Sign of Potential Improvement - Leukorrhea, an increase in vaginal discharge, may indicate a reduction in cervical mucus plug, which is a normal finding in late pregnancy.

BUN 40 mg/dL: Sign of Potential Worsening Condition - Elevated blood urea nitrogen (BUN) levels indicate impaired kidney function, which is a worsening sign of preeclampsia and can lead to complications such as acute kidney injury.