Exhibits

A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Complete the following sentence by using the lists of options. Because the newborn is exhibiting

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the nurse should plan to

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.

Choice A rationale

Applying warm packs during the initial 24 hours postpartum is generally contraindicated for an episiotomy site. Heat promotes vasodilation, which could increase swelling and edema in the traumatized perineal tissues, exacerbating pain and potentially increasing blood loss. Cold therapy, such as ice packs, is the preferred intervention initially, as it causes vasoconstriction, reducing localized edema and numbing the area for pain relief.

Choice B rationale

Encouraging the client to take a sitz bath twice daily is an appropriate intervention for an episiotomy, typically after the first 24 hours postpartum when the initial swelling has subsided. The warm water promotes vasodilation, which improves circulation to the perineal area. This enhanced blood flow facilitates healing and offers soothing relief from pain and discomfort, aiding in tissue regeneration and cleanliness.

Choice C rationale

Applying antibiotic ointment to a routine episiotomy is generally not recommended unless there are signs of infection or a specific prescription is provided. The wound is clean, and the risk of introducing pathogens outweighs the routine benefit. Proper hygiene with cleansing after elimination, using a peri-bottle with warm water, and changing pads frequently is the standard of care to prevent infection and promote natural healing.

Choice D rationale

Instructing the client to wipe the perineum with toilet tissue after voiding is incorrect and can be detrimental to episiotomy healing. Wiping, particularly from back to front, can introduce fecal bacteria into the episiotomy site or vagina, increasing the risk of infection. The client should be instructed to use a peri-bottle filled with warm water to gently rinse the area after elimination and then pat dry with a clean cloth or tissue.

Choice A rationale: A fundal height of 27 cm at 21 weeks gestation exceeds the expected range. Normally, fundal height in centimeters should approximate gestational age between 20 and 36 weeks, with a ±2 cm margin. At 21 weeks, a fundal height of 19–23 cm is acceptable. A measurement of 27 cm suggests possible fetal macrosomia, polyhydramnios, or gestational diabetes, especially in a client with elevated glucose levels and obesity. This warrants follow-up.

Choice B rationale: Fetal heart tones of 145/min fall within the normal range of 110 to 160 beats per minute. This rate reflects appropriate fetal autonomic regulation and oxygenation. Variability in fetal heart rate is expected and indicates a healthy intrauterine environment. No arrhythmia or bradycardia is present. Therefore, this finding does not require follow-up and supports normal fetal well-being at this gestational age.

Choice C rationale: A 1-hour glucose level of 220 mg/dL following a 100-g oral glucose load exceeds the threshold of less than 180 mg/dL. This result indicates impaired glucose tolerance and supports the diagnosis of gestational diabetes mellitus (GDM). GDM increases risks for fetal macrosomia, shoulder dystocia, and neonatal hypoglycemia. Follow-up is required to initiate dietary management, glucose monitoring, and possibly pharmacologic therapy to prevent maternal and fetal complications.

Choice D rationale: A 3-hour glucose level of 142 mg/dL exceeds the normal range of 70 to 115 mg/dL. This result confirms abnormal glucose metabolism and supports the diagnosis of gestational diabetes. The 3-hour value reflects delayed glucose clearance and persistent hyperglycemia. This finding, in conjunction with other elevated values, meets criteria for GDM and necessitates follow-up for glycemic control, nutritional counseling, and fetal surveillance to mitigate adverse outcomes.

Choice E rationale: A blood pressure of 140/88 mm Hg meets the threshold for gestational hypertension, defined as systolic ≥140 mm Hg or diastolic ≥90 mm Hg after 20 weeks gestation. Although the client denies symptoms of preeclampsia, such as headache or visual changes, her history of chronic hypertension and obesity increases risk. Continued monitoring and possible adjustment of antihypertensive therapy are warranted to prevent progression to preeclampsia or eclampsia.

Choice F rationale: Denial of headaches, visual disturbances, and epigastric pain suggests absence of preeclampsia symptoms. These symptoms reflect end-organ involvement and vasospasm in severe hypertensive disorders. Their absence supports stable maternal status. However, clinical vigilance remains important due to the client’s elevated blood pressure and risk factors. At this time, no follow-up is required solely based on symptom denial.