A nurse receives a handoff report.
Which newborn should the nurse assess first?

Choice A rationale

A glucose reading of 58 mg/dL in a newborn is below the normal range (typically 40-60 mg/dL in the first hours of life, rising to 50-90 mg/dL). While it requires attention and intervention to prevent hypoglycemia, it is not as immediately life-threatening as a significantly low temperature.

Choice B rationale

A temperature of 97.4°F (36.3°C) in a newborn is below the normal range (typically 97.7°F to 99.5°F or 36.5°C to 37.5°C). Hypothermia in a newborn can lead to cold stress, increased oxygen consumption, and hypoglycemia. This newborn needs immediate assessment and warming measures to prevent complications.

Choice C rationale

A respiratory rate of 48 breaths per minute is within the normal range for a newborn (typically 30-60 breaths per minute). While the nurse will continue to monitor the respiratory status, this finding does not indicate immediate distress.

Choice D rationale

A pulse rate of 134 beats per minute is within the normal range for a newborn (typically 110-160 beats per minute). While the nurse will continue to monitor the cardiovascular status, this finding does not indicate immediate distress. .

Choice A rationale

A dipstick value of 3+ for protein in the urine is a significant indicator of proteinuria, a key diagnostic criterion for preeclampsia. Preeclampsia is characterized by new-onset hypertension and proteinuria or other signs of end-organ damage in a previously normotensive pregnant woman. A 3+ protein level suggests substantial protein spillage into the urine, necessitating immediate attention to assess the severity of preeclampsia and prevent potential complications for both the mother and the fetus. Normal urine protein is typically negative to trace amounts.

Choice B rationale

Pitting pedal edema at the end of the day can be a common finding in pregnancy due to increased blood volume and pressure on the veins in the legs. While edema can be associated with preeclampsia, it is not a primary diagnostic criterion and can occur in normal pregnancies. Therefore, isolated pedal edema without other signs of preeclampsia is less concerning than significant proteinuria.

Choice C rationale

A blood pressure reading of 138/86 mm Hg is mildly elevated and falls within the range for stage 1 hypertension. While hypertension is a diagnostic criterion for preeclampsia, this isolated reading without a significant increase from baseline or other preeclampsia symptoms may not be the most urgent concern compared to significant proteinuria. Preeclampsia diagnosis requires a blood pressure of ≥140 mm Hg systolic or ≥90 mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive woman.

Choice D rationale

A weight gain of 0.5 kg (approximately 1.1 pounds) over two weeks is within the expected range for weight gain during pregnancy. While rapid or excessive weight gain can be a sign of fluid retention associated with preeclampsia, a modest gain of 0.5 kg over two weeks is not a primary indicator of the condition and is less concerning than significant proteinuria.