A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.
She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?

Choice A rationale

While it’s true that phytonadione, also known as vitamin K, plays a role in the immune system, this is not the primary reason it is given to newborns. Therefore, this statement does not show an understanding of why the medication is being given.

Choice B rationale

Phytonadione does not aid an immature liver. It is necessary for the synthesis of certain proteins required for blood clotting. However, it does not directly aid the liver’s function.

Choice C rationale

This is the correct statement. Phytonadione is given to newborns to prevent hemorrhagic disorders, specifically vitamin K deficiency bleeding (VKDB). Newborns are at risk for VKDB because their gut does not yet have the bacteria necessary to produce vitamin K5.

Choice D rationale

While it’s true that vitamin K is obtained from dietary intake, newborns do not receive phytonadione to compensate for insufficient dietary intake. They receive it to prevent VKDB, a bleeding disorder caused by vitamin K deficiency.

Choice A rationale

While a perineal hematoma can lead to increased WBC count, there is no indication of such a complication, making this assessment less immediate.

Choice B rationale

Assessing vital signs is an important part of routine postpartum care. Still, a white blood cell count of 15,000/mm is within a normal range for a woman within the first 24-48 hours after delivery and is not necessarily indicative of infection.

Choice C rationale

While an elevated WBC can indicate infection, a postpartum woman's white blood cell count can be normally elevated up to 20,000/mm due to the stress of labor and delivery. Checking a differential will provide a more accurate breakdown of different types of white blood cells for a more precise assessment.

Choice D rationale

A normal WBC in a postpartum client ranges from (12,000- 20, 000/mm. Checking the white blood cell differential helps determine the specific types of WBCs present and gives more information as to whether the elevation is the body's normal response to childbirth or a sign of infection.