A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

Choice A reason:

This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor. This is the correct answer because caput succedaneum is a swelling of the scalp that crosses the suture line and is caused by prolonged pressure on the baby's head during delivery. It can also result from the use of vacuum extraction or forceps. Caput succedaneum is harmless and usually resolves on its own within a few days.

Choice B reason:

This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin. This is incorrect because erythema toxicum is a common rash that affects newborns, but it does not cause swelling of the scalp or cross the suture line. It appears as red blotches with small white or yellow bumps that can occur anywhere on the body. Erythema toxicum is also harmless and usually disappears within a week.

Choice C reason:

This is a cephalhematoma, which will resolve on its own in 3 to 5 days. This is incorrect because cephalhematoma is bleeding under the scalp that does not cross the suture line and is caused by ruptured blood vessels in the scalp. It can also result from the use of vacuum extraction or forceps. Cephalhematoma may take weeks or months to resolve and can increase the risk of jaundice.

Choice D reason:

This is a Mongolian spot, which is found on many newborns. This is incorrect because Mongolian spots are bluish-gray patches of skin that are present at birth and are caused by melanocytes (pigment-producing cells) that are trapped in the deeper layers of the skin. They are not related to swelling or pressure on the head and usually fade by age 5.

Choice A reason:

Attachment phase is not one of Rubin's phases of role attachment. Rubin's theory of maternal role adaptation describes three stages that the mother goes through during the postpartum period: taking in, taking hold and letting go.

Choice B reason:

Letting go phase is the last stage of Rubin's theory of role attachment. It occurs when the mother accepts her new role and gives up her old roles. She also comes to terms with the reality of the birthing experience and the characteristics of her baby.

Choice C reason:

Taking hold phase is the second stage of Rubin's theory of role attachment. It occurs when the mother becomes interested in caring for the infant and learning about her baby and herself. She may be critical about her care-giving abilities and need positive reinforcement.

Choice D reason:

Taking in phase is the first stage of Rubin's theory of role attachment. It occurs right after the birth of the child, when the mother is passive and focused on her own needs, especially sleeping and eating. She may have limited interactions with her infant and prefer to talk about her experiences during labor, birth, and pregnancy. This matches the description of the new mother in the question, so this is the correct answer.