A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Choice A reason:

Placing a covering on the scale tray when weighing an infant helps to ensure that conductive heat loss from the infant is minimal. Newborns and infants are especially vulnerable to temperature changes, and maintaining their body temperature is crucial for their well-being. By placing a covering, such as a soft cloth or blanket, on the scale tray, the nurse creates a barrier between the infant's skin and the cold surface of the scale. This reduces the risk of heat loss from direct contact with the scale, helping to keep the baby comfortable and preventing any potential adverse effects from exposure to low temperatures during the weighing process.

Choice B reason:

Choice B, compensating for the negative weight balance to ensure the correct weight, is not the primary reason for using a covering on the scale tray. The negative weight balance, if any, would be minimal and not significant enough to affect the accuracy of the infant's weight measurement. The main concern when using a scale for weighing infants is to ensure their comfort and safety during the process.

Choice C reason:

Choice C, avoiding causing multiple startle (Moro) reflexes when weighing, is not the main reason for using a covering on the scale tray. The Moro reflex is a normal startle response in infants and is not typically affected by whether or not a covering is placed on the scale tray.

The nurse can support the infant appropriately during weighing to minimize any startle reflexes, regardless of whether a covering is used.

Choice D reason:

Choice D, avoiding contaminating the nurse's hands with blood or other body substances, is not directly related to using a covering on the scale tray. The primary purpose of using a covering is to minimize heat loss, as explained in Choice A. However, it is standard practice for healthcare professionals to wear gloves when handling blood or body substances to prevent any potential transmission of infections, ensuring both the nurse's and the infant's safety.

The correct answer is: a. Hyperbilirubinemia.

Choice A: Hyperbilirubinemia

Reason: Hyperbilirubinemia in newborns is often caused by the increased breakdown of red blood cells, which have a shorter lifespan in neonates. This breakdown produces bilirubin, a yellow pigment that can accumulate in the blood, leading to jaundice. The liver of a newborn is not fully mature and may not be able to process and excrete bilirubin efficiently, resulting in hyperbilirubinemia.

Choice B: Respiratory Distress Syndrome

Reason: Respiratory Distress Syndrome (RDS) is primarily caused by a deficiency of surfactant in the lungs, which is more common in premature infants. It is not directly related to the lifespan of red blood cells. Symptoms include rapid, shallow breathing and a bluish color due to lack of oxygen.

Choice C: Polycythemia

Reason: Polycythemia is characterized by an abnormally high concentration of red blood cells. It is often due to factors like delayed cord clamping or maternal diabetes, rather than the decreased lifespan of red blood cells. Polycythemia can lead to increased blood viscosity and complications such as sluggish blood flow.

Choice D: Transient Tachypnea

Reason: Transient Tachypnea of the Newborn (TTN) is a respiratory condition caused by delayed clearance of fetal lung fluid. It typically resolves within a few days and is not related to the lifespan of red blood cells. Symptoms include rapid breathing and grunting.