A nurse is assisting with the care of a newborn who is 4 hours old in the neonatal unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Choice A rationale

Retained placental fragments are a significant risk factor for postpartum hemorrhage. If parts of the placenta remain attached to the uterine wall, it can prevent the uterus from contracting properly, leading to excessive bleeding.

Choice B rationale

Breech presentation is not a direct risk factor for postpartum hemorrhage. While it can complicate delivery, it does not directly cause hemorrhage.

Choice C rationale

Urinary tract infection is not a risk factor for postpartum hemorrhage. It can cause other complications but does not directly lead to hemorrhage.

Choice D rationale

Oligohydramnios, or low amniotic fluid, is not a risk factor for postpartum hemorrhage. It can cause complications during pregnancy but does not directly lead to hemorrhage.

Choice A rationale:

Deep tendon reflexes of 1+ are considered normal and do not indicate any immediate concern. Reflexes are graded on a scale from 0 to 4+, with 2+ being normal. A 1+ reflex is slightly diminished but can be normal in some individuals.

Choice B rationale:

A pain rating of 3 on a scale of 0 to 10 is relatively low and manageable. Postpartum pain is expected, and a rating of 3 does not indicate severe pain that requires immediate intervention.

Choice C rationale:

The blood pressure reading of 136/86 mm Hg is slightly elevated but not alarming. Postpartum blood pressure can fluctuate, and this reading does not indicate a hypertensive crisis.

Choice D rationale:

Peripheral edema of 2+ in the bilateral lower extremities is common postpartum due to fluid retention and is not typically a cause for immediate concern unless accompanied by other symptoms such as severe pain or redness.

Choice E rationale:

Soft breasts with intact nipples are normal findings in the early postpartum period, especially if the client is breastfeeding. There is no indication of issues such as mastitis or engorgement.

Choice F rationale:

A large amount of lochia rubra is concerning as it may indicate postpartum hemorrhage. Lochia should gradually decrease in amount and change in color over time. A large amount of bright red blood suggests excessive bleeding that requires immediate follow-up.

Choice G rationale:

A soft uterine tone is abnormal and can indicate uterine atony, which is a leading cause of postpartum hemorrhage. The uterus should be firm and contracted to prevent excessive bleeding.

Choice H rationale:

Lateral deviation of the uterus can indicate a full bladder, which can prevent the uterus from contracting properly and lead to increased bleeding. This requires immediate attention to ensure the bladder is emptied and the uterus can contract effectively.