A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?

Choice A Reason:

Allowing the grandmother to push the baby to the room in a wheeled bassinet is not advisable. Hospitals have strict protocols to prevent infant abduction, and only authorized personnel should transport newborns. This ensures the safety and security of the infant.

Choice B Reason:

Requiring photo identification from the grandmother before allowing her to take the infant is not a standard practice. While identification is crucial, it is typically the responsibility of the hospital staff to transport the newborn to ensure proper security measures are followed.

Choice C Reason:

Having the mother call and the nurse taking the baby to the room is the most appropriate response. This ensures that the newborn is transported safely by authorized personnel, adhering to hospital protocols designed to prevent infant abduction and ensure the baby’s safety.

Choice D Reason:

Allowing the grandmother to carry the grandchild to the room is not recommended. Similar to choice A, this does not align with hospital security protocols. Only authorized personnel should handle the transportation of newborns within the hospital to maintain safety and security.

Choice A Reason:

Notifying the client’s provider is not immediately necessary in this scenario. The presence of lochia rubra and small clots is typical in the early postpartum period, especially when the fundus is firm and midline, indicating that the uterus is contracting well.

Choice B Reason:

Increasing the frequency of fundal massage is not required when the fundus is already firm and midline. Fundal massage is typically indicated if the uterus is boggy or not contracting adequately, which is not the case here

Choice C Reason:

Encouraging the client to empty her bladder is a good practice to prevent bladder distention, which can interfere with uterine contraction. However, it is not the priority action given the current findings.

Choice D Reason:

Documenting the findings and continuing to monitor the client is the most appropriate action. The observations are within normal limits for a client who is 1 hour postpartum. Continuous monitoring ensures that any changes in the client’s condition can be promptly addressed.