A nurse is preparing to collect a specimen for newborn screening.
Which of the following actions should the nurse take?

Choice A rationale

Deep tendon reflexes of 1+ are considered within normal limits and do not require immediate follow-up. This finding is not indicative of any acute complications.

Choice B rationale

A blood pressure reading of 136/86 mm Hg is slightly elevated but not critically high. It does not indicate an immediate risk and can be monitored with routine care.

Choice C rationale

A pain rating of 3 on a scale of 0 to 10 is mild and manageable. It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.

Choice D rationale

A large amount of lochia rubra can be a sign of excessive bleeding and requires immediate follow-up to assess for postpartum hemorrhage. This finding is concerning and needs prompt attention.

Choice E rationale

Peripheral edema of 2+ in bilateral lower extremities is common in the postpartum period due to fluid shifts and should resolve naturally. It does not require immediate follow-up unless it worsens or is accompanied by other symptoms.

Choice F rationale

Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding. This finding does not require immediate follow-up as it is a normal occurrence.

Choice G rationale

A soft uterine tone can indicate uterine atony, which can lead to hemorrhage. Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.

Choice H rationale

Lateral deviation of the uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention. This finding could lead to complications if not addressed promptly. .

Choice A rationale

Auscultating the newborn’s bowel sounds is important for assessing gastrointestinal function, but it is not the first priority in managing a newborn with neonatal abstinence syndrome (NAS). Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.

Choice B rationale

Swaddling the newborn in blankets can help provide comfort and reduce excessive stimulation, which is beneficial for newborns with NAS. However, it is not the first priority. The primary focus should be on assessing and stabilizing the newborn’s vital signs.

Choice C rationale

Weighing the newborn’s wet diaper is important for monitoring fluid balance and hydration status, but it is not the first priority in managing NAS. Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.

Choice D rationale

Determining the newborn’s respiratory rate is the first priority in managing a newborn with NAS. Assessing and stabilizing the newborn’s vital signs, including respiratory rate, is crucial to ensure the newborn’s immediate health and safety. .