A nurse is assisting with the care of a newborn 1 hr after birth.

Select the 5 findings that the nurse should report to the provider.

Choice A:

Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.

Choice B:

Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.

Choice C:

Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.

Choice D:

Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.

Choice E:

Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.

Choice A:

Lidocaine gel to the umbilical stump is not a medication that the nurse should expect to administer to a newborn immediately following birth. Lidocaine gel is a topical anesthetic that is used to numb the skin before procedures such as injections or sutures. It is not indicated for the umbilical stump, which does not require any anesthesia.

Choice B:

Hepatitis B immunization is a medication that the nurse should expect to administer to a newborn immediately following birth. Hepatitis B is a viral infection that can cause liver damage and cancer. The immunization protects the newborn from contracting the infection from the mother or other sources. The immunization is given as an intramuscular injection in the anterolateral thigh within 12 hours of birth.

Choice C:

Phytonadione injection is a medication that the nurse should expect to administer to a newborn immediately following birth. Phytonadione is also known as vitamin K, which is essential for blood clotting. Newborns have low levels of vitamin K at birth, which puts them at risk of bleeding disorders such as hemorrhagic disease of the newborn. The injection is given as a single dose of 0.5 to 1 mg in the vastus lateralis muscle within 1 hour of birth.

Choice D:

Antibiotic ophthalmic ointment is a medication that the nurse should expect to administer to a newborn immediately following birth. Antibiotic ophthalmic ointment prevents eye infections caused by bacteria such as gonorrhea or chlamydia, which can be transmitted from the mother during delivery. The ointment is applied to both eyes within 1 hour of birth.

Choice E:

Haemophilus influenzae type b vaccine (Hib) is not a medication that the nurse should expect to administer to a newborn immediately following birth. Hib is a bacterial infection that can cause meningitis, pneumonia, and other serious illnesses. The vaccine protects the newborn from Hib infection, but it is not given at birth. The vaccine is part of the routine immunization schedule and is usually given at 2, 4, and 6 months of age.