A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

A. "There are so many variables that you'll have to ask your obstetrician."

This response dismisses the client's question and fails to provide helpful information. While the client should discuss their specific situation with their obstetrician, the nurse should still offer some general guidance or information.

B. "The primary consideration is what type of incision was performed this time."

This is the correct response because it provides relevant information to the client's question. The type of incision made during the cesarean birth can influence the options for future deliveries. For example, a low transverse incision may make a vaginal birth after cesarean (VBAC) more likely, whereas a vertical incision might increase the likelihood of needing a repeat cesarean.

C. "A repeat cesarean birth is safer for both you and your baby."

This statement may not be accurate for all clients and situations. While repeat cesarean births are sometimes recommended for medical reasons, such as certain pregnancy complications or a previous cesarean with a vertical incision, it is not necessarily the safest option for all clients. This response also lacks consideration of the client's individual circumstances.

D. "It's too soon for you to be worrying about this now."

This response invalidates the client's concerns and fails to address their question. It's important to validate the client's feelings and provide them with accurate information to address their concerns.

A) Educate parents on blood glucose monitoring:

Blood glucose monitoring is not directly related to the care of a newborn with phenylketonuria (PKU). PKU is a metabolic disorder that affects the body's ability to process phenylalanine, an amino acid found in protein. Therefore, educating parents on blood glucose monitoring is not relevant to the management of PKU.

B) Obtain a blood sample for blood type:

Obtaining a blood sample for blood type is a routine procedure performed shortly after birth to determine the newborn's blood type and Rh factor. While this is an important aspect of newborn care, it is not specific to the management of PKU.

C) Administer thyroid hormone replacement:

Administering thyroid hormone replacement is not indicated for a newborn with PKU. PKU is a metabolic disorder caused by a deficiency of the enzyme phenylalanine hydroxylase, which leads to the accumulation of phenylalanine in the body. Thyroid hormone replacement is used to treat hypothyroidism, a condition involving an underactive thyroid gland, and is not related to PKU management.

D) Initiate a controlled low-protein diet:

Initiating a controlled low-protein diet is a crucial aspect of managing PKU. Since PKU is characterized by the inability to metabolize phenylalanine properly, dietary management aims to limit phenylalanine intake by implementing a low-protein diet. This diet helps prevent the accumulation of phenylalanine in the body, reducing the risk of neurological damage and other complications associated with PKU. Therefore, including this action in the plan of care is essential for effectively managing PKU in the newborn.