Examkin

Question

Difficulty: HardAnte/Intra/Postpartum and Newborn Care

A practical nurse (PN) is assigned to care for a client who is 12 hours postpartum following an uncomplicated vaginal delivery at 39 weeks gestation. The client's 12-hour-old neonate is rooming-in. Which action by the PN demonstrates safe and effective care within the scope of practice?

  1. Documenting that the neonate has a pink body with bluish hands and feet as an expected clinical findingAnswer
  2. B
    Reassuring the client that saturating a perineal pad with bright red blood every 30 minutes is a normal volume for lochia rubra
  3. C
    Accepting a delegated task to perform the comprehensive postpartum discharge assessment and finalize the nursing care plan
  4. D
    Alerting the registered nurse (RN) immediately because the neonate's toes fan outward when the lateral sole of the foot is stroked

Answer

The correct action is documenting that the neonate has a pink body with bluish hands and feet as an expected clinical finding.
The correct answer identifies acrocyanosis (bluish discoloration of the hands and feet with a pink central body), which is a normal, expected physiological finding in a neonate during the first 24 to 48 hours of life due to vasomotor instability. The PN is safely practicing within their scope by accurately recognizing and documenting this expected clinical finding without inappropriate escalation.

Step-by-Step Solution

1
Evaluate the neonate's skin color presentation
A pink central body with bluish hands and feet is identified as acrocyanosis
Vasomotor instability and sluggish peripheral circulation are normal in the first 24-48 hours of a neonate's life.
2
Determine the appropriate nursing intervention for acrocyanosis at 12 hours of life
The finding is recognized as normal and requires routine documentation
Because it is an expected physiological adaptation, it falls within the PN's scope to document the finding without urgently escalating it.
3
Evaluate the remaining options against the PN scope of practice and clinical safety
The other actions involve either missing a critical complication (hemorrhage), accepting an out-of-scope task, or inappropriately escalating a normal reflex
A PN must accurately differentiate expected data from abnormal data and only accept assignments within legal boundaries.

Key Concept

Prioritization and Professional Scope of Practice in Postpartum/Newborn Care
Estimated Time:1m 30s
Rate this question

Topics

Ante/Intra/Postpartum and Newborn Care

More questions from this topic