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Zorluk: OrtaAnte/Intra/Postpartum and Newborn Care

A nurse working on a maternal-newborn unit receives the change-of-shift report for four assigned clients. Which of the following clients should the nurse assess first?

  1. A
    A 4-hour-old neonate who has bluish discoloration of the hands and feet and an axillary temperature of 36.7°C (98.1°F).
  2. A 2-hour-old neonate who is exhibiting expiratory grunting, nasal flaring, and a resting respiratory rate of 74 breaths per minute.Cevap
  3. C
    A client in the active phase of labor whose electronic fetal monitor displays early decelerations during uterine contractions.
  4. D
    A client who is 2 days postpartum and reports profuse sweating during the night and frequent, copious urination.

Cevap

The 2-hour-old neonate who is exhibiting expiratory grunting, nasal flaring, and a resting respiratory rate of 74 breaths per minute requires immediate assessment.
The correct answer identifies a neonate in respiratory distress. Expiratory grunting, nasal flaring, and a resting respiratory rate of 74 breaths per minute (normal range is 30 to 60 breaths per minute) are critical signs of hypoxia that require immediate medical intervention to secure the airway and support breathing, aligning with the ABC (Airway, Breathing, Circulation) framework.

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1
Analyze the clinical status of the 4-hour-old neonate with bluish extremities.
Identify that acrocyanosis and an axillary temperature of 36.7°C (98.1°F) are normal physiological findings in an early neonate.
Differentiating between normal and abnormal findings is essential to rule out stable clients during triage.
2
Evaluate the neonate exhibiting grunting, flaring, and tachypnea.
Recognize that grunting, nasal flaring, and a respiratory rate of 74 breaths per minute (normal is 30 to 60) indicate severe respiratory distress.
According to the ABC (Airway, Breathing, Circulation) priority framework, an acute breathing compromise is a life-threatening emergency.
3
Assess the laboring client experiencing early decelerations.
Determine that early decelerations correspond to fetal head compression and are a benign, expected finding.
Accurate interpretation of fetal heart rate patterns prevents unnecessary emergency interventions for normal labor events.
4
Review the postpartum client experiencing night sweats and frequent urination.
Conclude that diaphoresis and diuresis are expected physiological processes designed to reduce excess blood volume after pregnancy.
Recognizing expected postpartum changes confirms that this client is stable and does not require immediate attention.
5
Compare all four clients to determine the highest priority.
Select the neonate with respiratory distress as the immediate priority.
The neonate is the only client experiencing an acute physiological instability that threatens life.

Anahtar Kavram

Prioritization of Care in Maternal-Newborn Nursing
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Konular

Ante/Intra/Postpartum and Newborn Care

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