A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out.
Which intervention would the nurse expect to include in the plan of care for this client?

Choice A rationale

Caput succedaneum is swelling of the soft tissues of the newborn's scalp, often caused by pressure during vaginal delivery. It is a separate condition from cephalohematoma, which involves bleeding between the periosteum and the skull bone. Therefore, cephalohematoma does not increase the risk for caput succedaneum.

Choice B rationale

Jaundice, or hyperbilirubinemia, is a common condition in newborns due to the breakdown of fetal red blood cells and the immature liver's inability to efficiently process bilirubin. Cephalohematomas involve the rupture of blood vessels, leading to an increased breakdown of red blood cells. This releases more bilirubin into the bloodstream, thus elevating the risk of jaundice in infants with cephalohematomas. Normal total bilirubin levels in newborns range from 1 to 12 mg/dL, varying with age in days.

Choice C rationale

Infection is a risk associated with any break in the skin or invasive procedure, but a cephalohematoma itself is a collection of blood beneath the periosteum and does not inherently create an open wound or direct pathway for infection. While infection of a cephalohematoma is possible, it is not a primary increased risk associated with its development.

Choice D rationale

Erythema toxicum is a common, benign skin rash seen in newborns, characterized by small, yellow-white papules or pustules surrounded by red skin. Its etiology is unknown but it is thought to be an inflammatory reaction of the hair follicles. It is not related to the presence or development of a cephalohematoma.

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.