A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

Rationale:

A. Gestational diabetes mellitus is not a contraindication for a contraction stress test. In fact, clients with gestational diabetes may require additional fetal monitoring due to the increased risk of fetal complications.

B. A previous classical incision, also known as a vertical uterine incision, increases the risk of uterine rupture during labor, making a contraction stress test contraindicated.

C. A previous stillbirth is not a contraindication for a contraction stress test. In fact, it may prompt additional fetal monitoring to assess for potential complications in subsequent pregnancies.

D. A nonreactive nonstress test may indicate the need for further evaluation with a contraction stress test; it is not a contraindication in itself.

Blood pressure 80/50 mm Hg: Indication of Potential Worsening Condition - A decrease in blood pressure may indicate hypovolemic shock due to ongoing or worsening postpartum hemorrhage.

Cloudy urine: Indication of Potential Worsening Condition - Cloudy urine may indicate a urinary tract infection or another complication, which can worsen the client's condition.

Moderate lochia rubra: Indication of Potential Worsening Condition - Continued moderate lochia rubra suggests ongoing or worsening postpartum hemorrhage.

Fundus firm to palpation: Indication of Potential Improvement - A firm fundus suggests effective uterine contraction and control of bleeding, indicating potential improvement.

Fundus at level of umbilicus: Indication of Potential Worsening Condition - The fundus being at the level of the umbilicus suggests uterine atony or continued bleeding, which is a worsening condition.