A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

Choice A reason:

A soft fundus indicates uterine atony, which is a lack of muscle tone that can lead to postpartum hemorrhage. A soft fundus is an abnormal finding and should be reported to the provider. The fundus should be firm and contracted to prevent bleeding.

Choice B reason:

A fundus that is 2 fingerbreadths above the umbilicus is too high for a client who is 12 hours postpartum. The fundus should descend about 1 centimeter per hour after delivery and should be at the level of the umbilicus at 12 hours postpartum. A high fundus could indicate retained placental fragments or a full bladder, both of which can interfere with uterine contraction and cause bleeding.

Choice C reason:

A fundus that is deviated to the right of the umbilicus is also an abnormal finding for a client who is 12 hours postpartum. A deviated fundus could indicate a full bladder, which can displace the uterus and prevent it from contracting properly. The fundus should be at the midline of the abdomen.

Choice D reason:

A fundus that is firm and at the level of the umbilicus is a normal finding for a client who is 12 hours postpartum. This indicates that the uterus is involuting (returning to its pre-pregnancy size and shape) and that there is no excessive bleeding. The nurse should expect this finding and document it accordingly.

Choice A reason:

Transferring the newborn to the NICU is not the best action to take next, because it does not address the immediate problem of low blood sugar. The newborn may need to be transferred to the NICU later, depending on the cause and severity of the hypoglycemia, but the first priority is to raise the blood glucose level.

Choice B reason:

Calling the lab for a STAT blood glucose level is not the best action to take next, because it will delay the treatment of hypoglycemia. The glucometer reading is a reliable indicator of low blood sugar, and waiting for a lab confirmation will waste valuable time. The nurse should act on the glucometer reading and initiate treatment as soon as possible.

Choice C reason:

Initiating breastfeeding is the best action to take next, because it will provide the newborn with a source of glucose that can raise the blood sugar level quickly. Breastfeeding also has other benefits for the newborn, such as promoting bonding, providing antibodies, and reducing the risk of infection. Breastfeeding should be initiated within the first hour of life for all newborns, unless contraindicated.

Choice D reason:

Recognizing this as a normal reading and documenting it is not the best action to take next, because it is not a normal reading for a 2 hour old newborn. The normal range of blood glucose for a newborn is 40 to 150 mg/dL. A reading of 32 mg/dL indicates hypoglycemia, which can have serious consequences for the newborn's brain development and function. Hypoglycemia should be treated promptly and documented accordingly.