A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Rationale for Correct Choices:

• Macrosomia: Post-term infants (≥ 42 weeks) are at higher risk of excessive birth weight due to prolonged nutrient exposure in utero. Larger infants are prone to birth trauma, shoulder dystocia, and hypoglycemia after delivery.

• Meconium aspiration syndrome: Thick green amniotic fluid indicates meconium passage in utero, likely due to fetal stress from prolonged labor and late decelerations. Inhalation of meconium-stained fluid at birth can cause airway obstruction, chemical pneumonitis, and respiratory distress.

Rationale for Incorrect Choices:

• Bronchopulmonary dysplasia: This chronic lung disease is typically a complication in premature infants requiring prolonged mechanical ventilation and high oxygen concentrations, not in post-term newborns.

• Intraventricular haemorrhage: This complication is primarily seen in premature infants with fragile germinal matrix vessels; it is uncommon in term or post-term neonates unless there is severe birth trauma or asphyxia.

Rationale for correct choices:

• Temperature 38.2° C (100.8° F): An elevated temperature in the postpartum period may indicate infection, particularly given the prolonged rupture of membranes and cesarean birth. Early recognition is essential to prevent progression to sepsis.
• Heart rate 104/min: Tachycardia can be an early sign of infection or postpartum hemorrhage. In combination with fever and elevated WBC, this warrants prompt evaluation.
• Client reports feeling unwell: The client’s report of illness is the first indicator of an ongoing disease process which warrants further evaluation, coupled by other findings, this indicates that there is something wrong.
• WBC count 33,000/mm³: This is markedly elevated beyond the normal postpartum range and indicates a possible systemic infection. This finding requires immediate intervention and notification of the provider.
• Fundus boggy but firmed with massage: A boggy uterus suggests uterine atony, which increases the risk of postpartum hemorrhage. Continuous monitoring is needed to prevent excessive blood loss.
• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a sign of endometritis or uterine infection. Early identification and treatment reduce the risk of sepsis and further complications.

Rationale for incorrect choices:

• Vital Signs Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97% on room air: This is within normal limits and does not indicate respiratory compromise at this time. Blood pressure is within normal postpartum range; no immediate intervention is needed. Oxygen saturation is adequate and does not require urgent follow-up.
• Breast firmness with moderate nipple discomfort: These findings are consistent with normal lactation and engorgement, and do not indicate an immediate complication.
• Surgical incision well-approximated with slight edema: Mild edema without redness or drainage is expected postoperatively and does not require immediate intervention.
• No bowel movement since birth, hypoactive bowel sounds: While monitoring is necessary for constipation, this is a common postpartum finding, especially after surgery and opioid use, and does not require urgent intervention.