A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz (4,139 grams), 21 inches long, TPR: 96.6° F (35.9° C), 158, 62, jittery, pink body with bluish hands and feet, crying.Which of the following nursing actions is of highest importance?

Choice A rationale

Reduction of fever is not a primary effect of carboprost tromethamine. This medication is primarily used to induce uterine contractions to manage postpartum hemorrhage.

Choice B rationale

While maintaining stable blood pressure is important, it is not the specific indicator of carboprost tromethamine's effectiveness. This medication is used to control bleeding.

Choice C rationale

Increased comfort, although significant, is not the direct effect of carboprost tromethamine. The primary aim is to induce uterine contractions to manage hemorrhage.

Choice D rationale

Decreased lochia rubra indicates the reduction of postpartum bleeding, which is the primary purpose of administering carboprost tromethamine. This outcome shows the medication is effective.

Choice A rationale

Numbness in the toes and heel might suggest nerve involvement but is not a typical sign of deep vein thrombosis (DVT), which involves the veins, not nerves.

Choice B rationale

Pain relieved by dorsiflexion (positive Homan's sign) is not reliable for diagnosing DVT. This symptom is outdated and not considered a definitive sign.

Choice C rationale

Spider-like and purple veins suggest superficial varicose veins, not deep vein thrombosis, which affects deeper veins and presents differently.

Choice D rationale

Swelling, redness, and warmth in the calf are classic signs of DVT due to the inflammation and obstruction of deep veins. These symptoms should prompt immediate medical evaluation and intervention. .