A nurse is caring for a term newborn who is 48 hr old

Exhibits

The nurse assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

A. Restrict daily oral fluid intake: Restricting oral fluid intake is not generally recommended unless there is a specific medical indication. Adequate hydration is important, especially postpartum, and fluid restriction may not be appropriate unless there are specific reasons to do so.

B. Administer an IV bolus of lactated Ringer’s: In a client with preeclampsia without severe features, intravenous fluid bolus administration is not the primary intervention. Fluid management is important, but it is typically done judiciously based on the client's specific needs, not as a routine IV bolus.

C. Obtain a prescription for misoprostol: Misoprostol is a medication that is sometimes used to prevent or treat postpartum hemorrhage but is not a routine intervention for a client with preeclampsia without severe features. The focus in preeclampsia management is on blood pressure control and monitoring for signs of worsening disease.

D. Assess for edema: This is the correct action. Assessing for edema is an important component of monitoring a client with preeclampsia. While edema is a common symptom in pregnancy, excessive or sudden-onset edema may be an indication of worsening preeclampsia.

A. The client will demonstrate proper bathing of the infant: This goal is more appropriate for later phases of postpartum adjustment when the mother becomes more involved in caring for her infant. During the taking-in phase, the focus is on the mother's own recovery.

B. The client will verbalize appropriate car seat safety: This goal is related to the safety and care of the newborn, and it may be more relevant in the taking-hold phase when the mother becomes more actively involved in caring for her baby.

C. The client will have adequate nutritional intake: This is the correct goal. Adequate nutritional intake is important for the mother's recovery, energy levels, and breastfeeding success. The nurse should assess and promote proper nutrition during the taking-in phase.

D. The client will identify individual family member roles: Family roles and dynamics are more commonly addressed in the postpartum adjustment phase known as the let-go phase, which occurs later as the mother becomes more comfortable and accepting of her new role.