The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?

Jaundice in an infant who is 4-hr old. This is because jaundice is a yellow discoloration of the skin and eyes caused by high levels of bilirubin in the blood. Jaundice usually appears between the second and fourth day after birth and lasts for one to two weeks. Jaundice that appears within the first 24 hours of life is considered early-onset jaundice and may indicate a serious problem, such as an infection, a blood type mismatch, or a liver disorder. The nurse should notify the charge nurse of this finding and request a blood test to check the bilirubin level.

Choice A is wrong because a hematocrit of 60% in an infant who is 8-hr old is not abnormal. Hematocrit is the percentage of red blood cells in the blood. Newborns normally have higher hematocrit levels than older children and adults because they have more red blood cells at birth.

Choice C is wrong because a blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old is not abnormal.

Blood glucose is the amount of sugar in the blood. Newborns normally have lower blood glucose levels than older children and adults because they have less glycogen (stored sugar) at birth.

Choice D is wrong because acrocyanosis in an infant who is 2-hr old is not abnormal. Acrocyanosis is a bluish discoloration of the hands and feet caused by poor circulation. Newborns normally have acrocyanosis for the first few days of life because they are adjusting to the temperature outside the womb.

Check the client's fundus. Lochia rubra is the normal vaginal bleeding and discharge that occurs after childbirth. It consists of blood, mucus, and tissue from the placenta and the uterus lining. It is usually bright red and may have some clots, but these clots should not be big or difficult to pass. If the client has a large amount of lochia rubra with several clots, it may indicate that the uterus is not contracting well and needs to be massaged to expel any retained tissue or blood. Checking the client's fundus is the first action the nurse should take to assess the uterine tone and location.

Choice A is incorrect because requesting the provider perform a vaginal examination is not the first action the nurse should take. A vaginal examination may be necessary if the fundal massage does not reduce the bleeding or if there is a suspicion of lacerations or hematoma, but it is not a priority intervention.

Choice C is incorrect because measuring the client's vital signs is not the first action the nurse should take. Vital signs can help monitor the client's hemodynamic status and identify signs of shock, such as tachycardia, hypotension, and pallor, but they are not as important as checking the fundus in this situation.

Choice D is incorrect because feeling for a full bladder is not the first action the nurse should take. A full bladder can displace the uterus and interfere with its contraction, leading to increased bleeding. However, it is not as likely as uterine atony to cause a large amount of lochia rubra with several clots.