A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

C) Massage the client's fundus to promote contractions:

Given the client's symptoms of excessive bleeding (soaked perineal pad in 10 minutes) and signs of hypovolemia (pale skin color, feeling weak, and light-headedness), massaging the client's fundus to promote contractions is the priority action. This intervention helps stimulate uterine contractions, which can aid in controlling postpartum hemorrhage by reducing uterine atony, a common cause of excessive bleeding after childbirth.

A) Administer oxytocin by continuous IV infusion:

While administering oxytocin by continuous IV infusion is a crucial intervention to promote uterine contractions and control bleeding in postpartum hemorrhage, massaging the fundus is the initial action to stimulate contractions directly. Oxytocin administration can follow fundal massage if the bleeding persists or worsens.

B) Tilt the client onto her right side with her legs elevated to at least 30°:

Positioning the client on her right side with legs elevated can improve venous return and cardiac output, but it is not the priority action in this scenario. Immediate treatment to address the potential cause of postpartum hemorrhage takes precedence over positioning adjustments.

D) Insert an indwelling urinary catheter:

Inserting a urinary catheter may be necessary to monitor urinary output and assess for bladder distention, especially if the client's fluid status needs close monitoring. However, it is not the priority action in this scenario, where addressing postpartum hemorrhage is the immediate concern

C) Cephalhematoma:

A cephalhematoma is a collection of blood between the skull bone and its periosteum. It appears as a raised, bruised area on the scalp and is typically limited by suture lines. Unlike caput succedaneum, which typically resolves within a few days and crosses suture lines, a cephalhematoma does not cross suture lines and may take weeks to months to resolve.

A) Caput succedaneum:

Caput succedaneum is a localized swelling of the soft tissues of the scalp, usually resulting from pressure against the dilating cervix during labor. It typically crosses suture lines and resolves within a few days.

B) Pilonidal dimple:

A pilonidal dimple is a small pit or sinus in the sacrococcygeal area, not related to scalp findings.

D) Molding:

Molding refers to the shaping of the fetal head to adapt to the birth canal during labor and delivery. It is a temporary deformity and does not involve bruising or raised areas on the scalp.