A nurse is caring for a newborn who is 56 hours old.
Vital signs at 0700: Heart rate 168/min, Respiratory rate 70/min, Temperature 36.1°C (97.0°F), Oxygen saturation 97%. The nurse reviews the assessment findings and determines the findings are consistent with which of the following complications?

Choice A rationale

A macrosomic baby, or a baby with a high birth weight, can stretch the uterus significantly, increasing the risk of postpartum hemorrhage. The overstretched uterus may not contract effectively after birth, leading to excessive bleeding.

Choice B rationale

Uterine involution refers to the process of the uterus returning to its pre-pregnancy size. Effective uterine involution typically reduces the risk of hemorrhage, rather than increasing it, as the contracting uterus helps compress blood vessels and control bleeding.

Choice C rationale

A first-degree laceration is a minor perineal tear that typically heals without significant intervention. While it can cause some bleeding, it is usually not sufficient to lead to postpartum hemorrhage. More severe lacerations (third or fourth degree) pose higher risks.

Choice D rationale

Endometriosis is a condition where tissue similar to the lining inside the uterus grows outside it. It does not directly increase the risk of postpartum hemorrhage. The condition primarily causes pain and fertility issues rather than acute bleeding post-delivery.

Choice A rationale

A red, tender area on the breast could indicate mastitis, an infection of the breast tissue. This requires prompt medical attention to prevent complications and provide appropriate treatment, often involving antibiotics.

Choice B rationale

A temperature of 100.8°F is considered a fever and could indicate an infection. Postpartum clients are at risk of infections, including endometritis, and should report any fever to their healthcare provider for further evaluation.

Choice C rationale

Burning on urination could indicate a urinary tract infection (UTI). UTIs are common postpartum due to catheter use and trauma during delivery. This symptom should be reported for evaluation and treatment if necessary.

Choice D rationale

Increased lochia rubra can indicate postpartum hemorrhage or retained placental fragments. Any significant change in bleeding pattern should be reported to ensure timely management and prevent serious complications.