The nurse is reviewing the client’s chart.

Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage.

Client was middle aged and married.

She was in labor for 25 hours and forceps were used to assist with the delivery.

She was given an epidural for anesthesia that was effective.

The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale.

Her vital signs were stable, and she was catheterized for 500 mL of light-yellow urine just prior to delivery.

Her spouse was at the bedside for delivery.

Choice A rationale
Hypoglycemia is a low blood glucose level that can occur in newborns who have macrosomia and whose mothers have diabetes mellitus. This is because the fetus produces excess insulin in response to the high maternal glucose levels, and after birth, the insulin level remains high while the glucose level drops. Hypoglycemia can cause seizures, lethargy, poor feeding, and brain damage in the newborn.

Choice B rationale
Hypomagnesemia is a low magnesium level that can occur in newborns who have intrauterine growth restriction (IUGR) and whose mothers have preeclampsia. This is because the placental insufficiency and the maternal hypertension impair the magnesium transfer to the fetus. Hypomagnesemia can cause tremors, irritability, hypotonia, and cardiac arrhythmias in the newborn.

Choice C rationale
Hyperbilirubinemia is a high bilirubin level that can occur in newborns who have hemolytic disease of the newborn (HDN) and whose mothers have Rh incompatibility or ABO incompatibility. This is because the maternal antibodies destroy the fetal red blood cells, which release bilirubin. Hyperbilirubinemia can cause jaundice, kernicterus, and brain damage in the newborn.

Choice D rationale
Hypocalcemia is a low calcium level that can occur in newborns who are preterm, small for gestational age (SGA), or have perinatal asphyxia. This is because the immature parathyroid gland, the low body fat, or the hypoxia impair the calcium regulation in the newborn. Hypocalcemia can cause jitteriness, tetany, seizures, and cardiac arrhythmias in the newborn.

Choice A rationale
This is correct because blood pressure 80/56 mm Hg is the nurse's priority finding. It indicates hypotension, which is a common and serious complication of epidural analgesia. Hypotension can compromise the maternal and fetal perfusion and oxygenation, leading to fetal distress and acidosis. The nurse should immediately administer oxygen, fluids, and vasopressors as prescribed, and monitor the fetal heart rate and variability.

Choice B rationale
This is incorrect because temperature 38.2°C (100.8°F) is not the nurse's priority finding. It indicates a fever, which could be a sign of infection or dehydration. The nurse should assess the client for other signs of infection, such as chills, malaise, or foul-smelling discharge, and administer antipyretics and antibiotics as prescribed. The nurse should also ensure adequate hydration and cooling measures for the client.

Choice C rationale
This is incorrect because the client reports weakness of the lower extremities is not the nurse's priority finding. It indicates a side effect of epidural analgesia, which blocks the nerve impulses from the lower spinal segments. The nurse should assess the client's motor and sensory function, and adjust the epidural infusion rate as prescribed. The nurse should also assist the client with positioning and mobility, and prevent pressure ulcers and nerve injuries.

Choice D rationale
This is incorrect because the client reports profuse itching is not the nurse's priority finding. It indicates a side effect of opioid epidural analgesia, which stimulates the histamine receptors in the skin. The nurse should assess the client's skin condition, and administer antihistamines as prescribed. The nurse should also provide comfort measures, such as cool compresses, lotion, or massage, for the client.