A nurse on a postpartum unit is caring for a client.

Exhibits

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Nurses' Notes

2hr postpartum:

Client is 2 hr postpartum following vaginal delivery. Client alert and oriented. Lungs clear to auscultation bilaterally. S1 S2 auscultated, no murmur. Abdomen soft, nontender. Uterus firm and midline, 1 cm below the umbilicus. Moderate amount of lochia rubra present on perineal pad.

24 hr postpartum:

Client alert and oriented. Lungs clear to auscultation bilaterally. S1,S2 auscultated, no murmur. Abdomen soft, nontender. Uterus boggy and midline, 2 cm below the umbilicus. Moderate amount of lochia rubra present on perineal pad, foul odor present.

Vital signs:

1 hr postpartum:

Temperature 37.5° C (99.5° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 118/78 mm Hg

24 hr postpartum:

Temperature 38.3° C (100.9° F)

Heart rate 105/min

Respiratory rate 18/min

Blood pressure 115/78 mm Hg

A) "Have you had any health concerns during your pregnancy?"
While it's important to assess the client's overall health and pregnancy history, this question doesn't directly address the current concern of possible labor and does not immediately help assess the client's status for labor evaluation. The focus should be on signs of labor or complications at this point.

B) "Do you have a support person present?"
Although this is a helpful question to ask in preparation for labor, it doesn't provide the necessary information needed to assess whether the client is in labor. The priority at this stage is determining if the client is in labor or experiencing any complications, such as rupture of membranes.

C) "Have you noticed any fluid leaking from your vagina?"
This is the most important question to ask next. If the client has ruptured membranes (i.e., water breaking), it is important to assess the timing and nature of the fluid leakage, as it would indicate the need for immediate evaluation at the hospital. Rupture of membranes requires monitoring for infection and should prompt the client to come in for assessment regardless of the frequency or intensity of contractions.
D) "When was your last prenatal visit?"
While it is helpful to know when the client had their last prenatal visit, this question does not directly address the issue of possible labor. The priority is to determine if the client is in labor, whether their membranes have ruptured, or if there are any other complications such as bleeding or abnormal fetal movement. The question about fluid leakage is more immediate and relevant to their current condition.

A) Fusion of labia in female genitalia:
Fusion of the labia in a female newborn is not an expected finding. This could indicate a condition such as labial adhesion or an abnormality in the development of the genitalia. Normally, the labia in a female newborn are separated. Any signs of fusion would require further evaluation by the healthcare provider.

B) Erythema toxicum on newborn's skin:
Erythema toxicum is a common and expected finding in newborns, usually appearing within the first 2–3 days of life. It consists of small, red papules or pustules on a red base, often described as a "flea-bitten" appearance. This rash is benign and resolves on its own within a few days to weeks. It is not associated with any infection or underlying health issues.

C) Hypospadias is noted in the male newborn:
Hypospadias, a condition where the urethral opening is located on the underside of the penis rather than at the tip, is not an expected finding in all newborn males. While it occurs in a small percentage of male infants, it is a congenital anomaly that would require further assessment and possibly surgical correction. It is not considered a normal finding in a newborn.

D) Presence of syndactyly in extremities:
Syndactyly, the condition where two or more fingers or toes are fused together, is not a normal finding in newborns. While it is a congenital anomaly that can occur in some infants, it is not expected and requires further evaluation and possibly surgical intervention depending on the severity.

E) Negative Ortolani sign:
A negative Ortolani sign is an expected and normal finding in a newborn. The Ortolani maneuver is used to assess for hip dislocation, and a negative result indicates that the hip is stable and not dislocated. If the Ortolani sign were positive, it would suggest the presence of a developmental hip dysplasia, which would require further diagnostic evaluation. A negative sign is considered typical and reassuring.