A nurse in a prenatal clinic is determining a client's estimated date of delivery using Naegele's rule.
The first day of her last menstrual period was April 4, 2023.
Which of the following dates should the nurse tell the client is her estimated date of delivery (EDD)?

Choice A rationale:

The purpose of administering vitamin K to a newborn is to prevent bleeding. Vitamin K plays a crucial role in blood clotting. Newborns often have lower levels of vitamin K, which can make them more susceptible to bleeding disorders, such as hemorrhagic disease of the newborn (HDN). HDN can lead to serious bleeding complications, including intracranial hemorrhage, which can be life-threatening.

Choice B rationale:

Hyperbilirubinemia is not the primary purpose of administering vitamin K. While vitamin K can indirectly help in preventing jaundice (hyperbilirubinemia) by reducing the risk of bleeding that may lead to hemolysis, it is not the primary aim of vitamin K administration.

Choice C rationale:

Potassium deficiency (hypokalemia) is not a primary concern related to vitamin K administration. Vitamin K is specifically administered to prevent bleeding disorders and not to address potassium levels.

Choice D rationale:

Infection is not related to the administration of vitamin K. Vitamin K is not used to prevent or treat infections in newborns; its primary role is in blood clotting.

Answer and explanation

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7°C (100°F); pulse rate 88/min; respiratory rate 18/min. Which of the following actions should the nurse perform? The correct answer is Choice A: Report the client's temperature elevation.

Choice A rationale:

The nurse should report the client's temperature elevation because a temperature of 37.7°C (100°F) is above the normal range for a postpartum client. A postpartum temperature greater than 100.4°F (38°C) may indicate an infection, such as endometritis or mastitis. It is essential to identify and treat infections promptly to prevent complications.

Choice B rationale:

Asking the client to empty her bladder is not the most appropriate action in this situation. While bladder distention can sometimes cause uterine displacement, the elevated temperature is a more urgent concern. The nurse should address the temperature issue first.

Choice C rationale:

Increasing IV fluids is not indicated based on the information provided. The client's temperature elevation and soft breasts are concerning, and increasing IV fluids will not address these issues. It's essential to focus on the potential infection first.

Choice D rationale:

Encouraging the client to nurse more frequently to stimulate milk production is not the priority in this scenario. While breastfeeding is essential for milk production and uterine involution, the client's elevated temperature and other findings should be addressed first.