A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

• Color: Consistent with genetic background

  • Interpretation: B) Sign of potential improvement
  • Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.

• Axillary Temperature: 36.3°C (97.4°F)

  • Interpretation: B) Sign of potential improvement
  • Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.

• Reflex Irritability: Cry

  • Interpretation: B) Sign of potential improvement
  • Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.

• Muscle Tone: Flaccid

  • Interpretation: C) Sign of potential worsening condition
  • Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.

• Respiration Effort: Good cry

  • Interpretation: B) Sign of potential improvement
  • Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.

• Heart Rate: 140/min

  • Interpretation: B) Sign of potential improvement
  • Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.

Choice A rationale:
Glucose level is within the normal range (40 to 60 mg/dL), so it's not a complication.
Choice B rationale:
Caput succedaneum is a common finding in newborns who were delivered vaginally and is not a complication.
Choice C rationale:
A negative Coombs test is a normal finding and does not indicate a complication.
Choice D rationale:
Yellow sclera in a newborn can be a sign of jaundice, which should be reported to the provider.
Choice E rationale:
Heart rate is slightly elevated but within the normal range for a newborn (100-160/min), so it's not a complication.
Choice F rationale:
The newborn has not passed meconium stool since birth, which should be reported to the provider as it could indicate a complication.
Choice G rationale:
Dry mucous membranes can be a sign of dehydration, which should be reported to the provider.
Choice H rationale:
Respiratory rate is within the normal range for a newborn (30-60/min), so it's not a complication.