A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.
Which assessment action should the nurse prioritize?

Choice C rationale

Amenorrhea, or the absence of menstruation, is often the first and most reliable sign of pregnancy. If a woman is in her childbearing years and a week or more has passed without the start of an expected menstrual cycle, she might be pregnant.

Choice A rationale

Hegar’s sign is a physical examination finding that can be indicative of pregnancy. However, it is not typically used as the primary indicator of pregnancy because it requires a pelvic examination and is less reliable than other signs such as amenorrhea.

Choice B rationale

While breast tenderness can be a symptom of early pregnancy, it is not the most reliable indicator. Many other conditions or factors, such as hormonal fluctuations related to the menstrual cycle, can also cause breast tenderness.

Choice D rationale

Morning sickness, characterized by nausea and vomiting, is a common symptom of early pregnancy. However, not all pregnant women experience morning sickness, and it can also be caused by other conditions. Therefore, it is not the most reliable indicator of pregnancy.

Choice A rationale

Abruptio placenta is a condition where the placenta prematurely separates from the uterus. It typically presents with symptoms such as vaginal bleeding, back pain, and frequent contractions. However, the symptoms described by the client do not align with this condition.

Choice B rationale

Chorioamnionitis is an infection of the membranes surrounding the fetus and is associated with prolonged labor. Symptoms include fever, abdominal pain, and fetal tachycardia. The client’s symptoms of pain when the baby moves, a high temperature, and severe abdominal or uterine tenderness on palpation align with this condition.

Choice C rationale

Round ligament strain is a common cause of pain during pregnancy, particularly in the second trimester. It is caused by the stretching of the round ligaments that support the uterus.

However, it does not cause fever or severe abdominal tenderness.

Choice D rationale

While a viral infection could potentially cause a fever, it would not typically cause severe abdominal or uterine tenderness specifically when the baby moves.