A) Increase the client's fluid intake:

While maintaining adequate hydration is essential for postpartum recovery, it is not the priority intervention in this situation. The client's increased blood loss requires immediate attention to prevent complications such as hemorrhage.

B) Prepare to administer oxytocic medication:

Oxytocic medication may be indicated to stimulate uterine contractions and control bleeding in postpartum clients experiencing excessive bleeding. However, before administering medication, assessing the client's condition and determining the cause of bleeding is necessary to ensure appropriate intervention.

C) Palpate the client's uterine fundus:

This is the priority nursing intervention. Saturating two perineal pads with blood in a 30-minute period suggests excessive bleeding, which could be due to uterine atony or other postpartum complications. Palpating the uterine fundus helps assess for uterine tone, position, and any signs of uterine atony. If the fundus is boggy or deviated from the midline, it indicates uterine atony and requires immediate intervention.

D) Assist the client on a bedpan to urinate:

While assisting the client with urination is important for comfort and prevention of urinary retention, it is not the priority intervention in this situation. Assessing and managing the cause of excessive bleeding take precedence to prevent further complications.

A) Less than 2.5 cm of rubra lochia on perineal pad:

The amount of lochia on the perineal pad is an indicator of postpartum bleeding and uterine involution but does not specifically indicate bladder distention.

B) Client report of increased thirst:

Increased thirst may indicate dehydration, which can occur postpartum, but it is not a specific sign of bladder distention.

C) Fundus palpable to right of midline:

This finding suggests bladder distention. A full bladder can displace the uterus to the right side of the midline. Bladder distention can hinder uterine contractions and increase the risk of postpartum hemorrhage. Emptying the bladder can help the uterus contract effectively and prevent complications.

D) Client report of frequent uterine contractions:

Frequent uterine contractions are expected in the immediate postpartum period as the uterus undergoes involution. However, this finding does not specifically indicate bladder distention.

A) Initiate early feeding:

Early and frequent breastfeeding or formula feeding helps stimulate bowel movements, which aid in the elimination of bilirubin from the body. Breast milk also contains substances that promote bilirubin excretion, making early feeding an effective preventive measure against neonatal jaundice.

B) Suction excess mucus with a bulb syringe:

While clearing excess mucus can facilitate breathing and feeding, it does not directly prevent jaundice.

C) Prepare for an exchange blood transfusion:

Exchange transfusion is a treatment option for severe jaundice that has not responded to other measures. It is not a preventive measure.

D) Begin phototherapy:

Phototherapy is a treatment for jaundice after it has occurred, not a preventive measure. It involves exposing the newborn's skin to specific wavelengths of light to break down excess bilirubin.

C) Cephalhematoma:

A cephalhematoma is a collection of blood between the skull bone and its periosteum. It appears as a raised, bruised area on the scalp and is typically limited by suture lines. Unlike caput succedaneum, which typically resolves within a few days and crosses suture lines, a cephalhematoma does not cross suture lines and may take weeks to months to resolve.

A) Caput succedaneum:

Caput succedaneum is a localized swelling of the soft tissues of the scalp, usually resulting from pressure against the dilating cervix during labor. It typically crosses suture lines and resolves within a few days.

B) Pilonidal dimple:

A pilonidal dimple is a small pit or sinus in the sacrococcygeal area, not related to scalp findings.

D) Molding:

Molding refers to the shaping of the fetal head to adapt to the birth canal during labor and delivery. It is a temporary deformity and does not involve bruising or raised areas on the scalp.

A. "There are so many variables that you'll have to ask your obstetrician."

This response dismisses the client's question and fails to provide helpful information. While the client should discuss their specific situation with their obstetrician, the nurse should still offer some general guidance or information.

B. "The primary consideration is what type of incision was performed this time."

This is the correct response because it provides relevant information to the client's question. The type of incision made during the cesarean birth can influence the options for future deliveries. For example, a low transverse incision may make a vaginal birth after cesarean (VBAC) more likely, whereas a vertical incision might increase the likelihood of needing a repeat cesarean.

C. "A repeat cesarean birth is safer for both you and your baby."

This statement may not be accurate for all clients and situations. While repeat cesarean births are sometimes recommended for medical reasons, such as certain pregnancy complications or a previous cesarean with a vertical incision, it is not necessarily the safest option for all clients. This response also lacks consideration of the client's individual circumstances.

D. "It's too soon for you to be worrying about this now."

This response invalidates the client's concerns and fails to address their question. It's important to validate the client's feelings and provide them with accurate information to address their concerns.

A. Place an identification bracelet:

While important for identification purposes, placing an identification bracelet is not the priority immediately following birth. Ensuring the newborn's physiological stability takes precedence.

B. Administer eye prophylaxis:

Administering eye prophylaxis is an essential newborn care procedure to prevent neonatal conjunctivitis caused by exposure to maternal gonorrhea or chlamydia. However, it is not the priority immediately after ensuring a patent airway.

C. Administer vitamin K:

Administering vitamin K is important for preventing vitamin K deficiency bleeding (VKDB) in newborns. However, it is typically done after drying the skin and other immediate newborn care tasks.

D. Dry the skin:

This is the correct answer. Drying the newborn's skin is the priority after ensuring a patent airway. Drying helps prevent heat loss and stimulates the newborn's breathing and circulation. It is an essential step in newborn care immediately after birth to promote thermal stability and adaptation to extrauterine life.

A) "I'll make sure his diaper is loose in the front":

This statement indicates understanding because ensuring a loose diaper helps prevent irritation and discomfort to the healing circumcision site. Tight diapers can rub against the area and cause irritation or disrupt the healing process.

B) "I'll apply petroleum jelly to his penis with diaper changes":

While applying petroleum jelly to the penis with diaper changes is a common practice for circumcision care, it is not recommended for the Plastibell technique. Using petroleum jelly can interfere with the plastic ring and may prevent it from falling off naturally.

C) "I'll expect the plastic ring to fall off by itself within a week":

This statement indicates understanding because with the Plastibell technique, the plastic ring is left in place until it falls off on its own, typically within a week after the procedure. It is essential for the client to be aware of this expected outcome.

D) "I'll call the doctor if I see any bleeding":

This statement indicates understanding because it shows recognition of the potential complication of bleeding post-circumcision. While some minor bleeding may occur initially, excessive bleeding should be reported to the doctor promptly for further evaluation and management.

E) "I'll wash his penis with warm water and mild soap each day":

While keeping the area clean with warm water and mild soap is generally recommended for circumcision care, with the Plastibell technique, it is typically advised to avoid washing the area directly until the plastic ring falls off. Direct washing may interfere with the healing process or disrupt the plastic ring. Therefore, this statement does not indicate understanding of circumcision care with the Plastibell technique.

A) "You may carry your grandchild to the room":

While it may seem like a polite and accommodating response, allowing the grandmother to carry the newborn to the mother's room poses potential risks. Without proper training and supervision, there is a risk of mishandling or dropping the newborn, especially if the grandmother is unfamiliar with newborn care practices. Therefore, this response does not prioritize the safety and security of the newborn.

B) "Have the mother call and I will take the baby to the room":

This response places the responsibility on the mother to initiate the transfer of the newborn to the room. While it ensures that the mother is aware of and consenting to the movement of the newborn, it may cause delays in reuniting the newborn with the mother. Additionally, if the mother is unable to call or communicate immediately, it could prolong the separation between the newborn and the mother.

C) "If you show me your photo identification, you can take the infant":

Requesting photo identification from the grandmother may seem like a security measure to ensure that only authorized individuals handle the newborn. However, allowing non-staff members to transport newborns without proper supervision or training raises safety concerns. Without proper verification of the grandmother's identity against authorized visitors or family members, this approach may compromise the safety and security of the newborn.

D) "You can push the baby to the room in a wheeled bassinet":

This response prioritizes the safety and security of the newborn by providing a safe and appropriate means of transportation to the mother's room. Using a wheeled bassinet ensures that the newborn is securely positioned and protected during transit. It also aligns with hospital protocols for the safe movement of newborns within the facility, minimizing the risk of accidents or mishaps. Therefore, this response is the most appropriate option to ensure the well-being of the newborn while facilitating the grandmother's desire to take the baby to the mother's room.

A) "I should place my baby's crib next to the heater to keep him warm during the winter":

Placing the baby's crib next to a heater poses a risk of overheating and burns, which can be dangerous for the newborn. This statement indicates a misunderstanding of crib safety and puts the baby at risk of injury.

B) "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps":

Padding the mattress in the baby's crib increases the risk of suffocation and SIDS. Soft bedding, including padded mattresses, should be avoided to maintain a safe sleep environment for the baby. This statement indicates a lack of understanding of safe sleep practices.

C) "I should remove extra blankets from my baby's crib":

Removing extra blankets from the baby's crib is a crucial aspect of crib safety. Extra bedding increases the risk of suffocation and SIDS, so it's essential to keep the crib free of loose blankets, pillows, and other soft items. This statement indicates an understanding of safe sleep practices and prioritizes the baby's safety.

D) "I will place my baby on his stomach when he is sleeping":

Placing the baby on his stomach for sleep increases the risk of SIDS. The American Academy of Pediatrics recommends placing babies on their backs to sleep to reduce the risk of sudden unexpected infant death. This statement indicates a misunderstanding of safe sleep practices and poses a risk to the baby's safety.

A) The client is immune to the rubella virus:

A negative rubella titer indicates that the client is not immune to the rubella virus. Therefore, this interpretation is incorrect.

B) The client requires a rubella vaccination at this time:

A negative rubella titer indicates susceptibility to rubella and the need for vaccination. However, administering a live virus vaccine like rubella during pregnancy is contraindicated due to the risk of fetal harm. Therefore, this interpretation is incorrect.

C) The client requires a rubella immunization following delivery:

A negative rubella titer during pregnancy indicates susceptibility to rubella. After delivery, the client should receive a rubella immunization to prevent rubella infection in future pregnancies. Rubella vaccination is safe postpartum and helps protect the mother and future pregnancies. Therefore, this interpretation is correct.

D) The client is not experiencing a rubella infection at this time:

A rubella titer measures the level of antibodies to the rubella virus, not the presence of an active infection. A negative rubella titer indicates the absence of immunity to rubella, not the absence of an active infection. Therefore, this interpretation is incorrect.