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Orthostatic hypotension:Orthostatic hypotension, although it can occur postpartum due to changes in fluid volume and hormone levels, is not typically an immediate sign of a postpartum complication. It may occur as the body adjusts to changes after delivery but is not necessarily indicative of a complication on its own.

Fundus palpable at the umbilicus:
A fundus palpable at the umbilicus is a normal finding for a client who is 12 hr postpartum. Immediately after delivery, the fundus is typically firm and located at or just below the level of the umbilicus. Over time, it should descend and become firmer as the uterus involutes.

Urine output of 3,000 mL in 12 hr:An unusually high urine output of 3,000 mL in 12 hr may indicate excessive fluid loss, which could be a sign of postpartum hemorrhage. While it is essential for postpartum clients to void frequently to prevent urinary retention, such a high output warrants further investigation by the nurse to rule out complications.

Increase the client's fluid intake:While maintaining adequate hydration is essential for postpartum recovery, it is not the priority intervention in this situation. The client's increased blood loss requires immediate attention to prevent complications such as hemorrhage.

Prepare to administer oxytocic medication:Oxytocic medication may be indicated to stimulate uterine contractions and control bleeding in postpartum clients experiencing excessive bleeding. However, before administering medication, assessing the client's condition and determining the cause of bleeding is necessary to ensure appropriate intervention.

Assist the client on a bedpan to urinate:While assisting the client with urination is important for comfort and prevention of urinary retention, it is not the priority intervention in this situation. Assessing and managing the cause of excessive bleeding take precedence to prevent further complications.

Less than 2.5 cm of rubra lochia on perineal pad:The amount of lochia on the perineal pad is an indicator of postpartum bleeding and uterine involution but does not specifically indicate bladder distention.

Client report of increased thirst:Increased thirst may indicate dehydration, which can occur postpartum, but it is not a specific sign of bladder distention.

Client report of frequent uterine contractions:Frequent uterine contractions are expected in the immediate postpartum period as the uterus undergoes involution. However, this finding does not specifically indicate bladder distention.

Suction excess mucus with a bulb syringe:While clearing excess mucus can facilitate breathing and feeding, it does not directly prevent jaundice.

Prepare for an exchange blood transfusion:
Exchange transfusion is a treatment option for severe jaundice that has not responded to other measures. It is not a preventive measure.

Begin phototherapy:Phototherapy is a treatment for jaundice after it has occurred, not a preventive measure. It involves exposing the newborn's skin to specific wavelengths of light to break down excess bilirubin.

Caput succedaneum:Caput succedaneum is a localized swelling of the soft tissues of the scalp, usually resulting from pressure against the dilating cervix during labor. It typically crosses suture lines and resolves within a few days.

Pilonidal dimple:
A pilonidal dimple is a small pit or sinus in the sacrococcygeal area, not related to scalp findings.

Molding:Molding refers to the shaping of the fetal head to adapt to the birth canal during labor and delivery. It is a temporary deformity and does not involve bruising or raised areas on the scalp.

"There are so many variables that you'll have to ask your obstetrician."This response dismisses the client's question and fails to provide helpful information. While the client should discuss their specific situation with their obstetrician, the nurse should still offer some general guidance or information.

"A repeat cesarean birth is safer for both you and your baby."
This statement may not be accurate for all clients and situations. While repeat cesarean births are sometimes recommended for medical reasons, such as certain pregnancy complications or a previous cesarean with a vertical incision, it is not necessarily the safest option for all clients. This response also lacks consideration of the client's individual circumstances.

"It's too soon for you to be worrying about this now."This response invalidates the client's concerns and fails to address their question. It's important to validate the client's feelings and provide them with accurate information to address their concerns.

Place an identification bracelet:While important for identification purposes, placing an identification bracelet is not the priority immediately following birth. Ensuring the newborn's physiological stability takes precedence.

Administer eye prophylaxis:Administering eye prophylaxis is an essential newborn care procedure to prevent neonatal conjunctivitis caused by exposure to maternal gonorrhea or chlamydia. However, it is not the priority immediately after ensuring a patent airway.

Administer vitamin K:
Administering vitamin K is important for preventing vitamin K deficiency bleeding (VKDB) in newborns. However, it is typically done after drying the skin and other immediate newborn care tasks.

"You may carry your grandchild to the room":While it may seem like a polite and accommodating response, allowing the grandmother to carry the newborn to the mother's room poses potential risks. Without proper training and supervision, there is a risk of mishandling or dropping the newborn, especially if the grandmother is unfamiliar with newborn care practices. Therefore, this response does not prioritize the safety and security of the newborn.

"Have the mother call and I will take the baby to the room":This response places the responsibility on the mother to initiate the transfer of the newborn to the room. While it ensures that the mother is aware of and consenting to the movement of the newborn, it may cause delays in reuniting the newborn with the mother. Additionally, if the mother is unable to call or communicate immediately, it could prolong the separation between the newborn and the mother.

"If you show me your photo identification, you can take the infant":
Requesting photo identification from the grandmother may seem like a security measure to ensure that only authorized individuals handle the newborn. However, allowing non-staff members to transport newborns without proper supervision or training raises safety concerns. Without proper verification of the grandmother's identity against authorized visitors or family members, this approach may compromise the safety and security of the newborn.

"I should place my baby's crib next to the heater to keep him warm during the winter":Placing the baby's crib next to a heater poses a risk of overheating and burns, which can be dangerous for the newborn. This statement indicates a misunderstanding of crib safety and puts the baby at risk of injury.

"I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps":Padding the mattress in the baby's crib increases the risk of suffocation and SIDS. Soft bedding, including padded mattresses, should be avoided to maintain a safe sleep environment for the baby. This statement indicates a lack of understanding of safe sleep practices.

"I will place my baby on his stomach when he is sleeping":Placing the baby on his stomach for sleep increases the risk of SIDS. The American Academy of Pediatrics recommends placing babies on their backs to sleep to reduce the risk of sudden unexpected infant death. This statement indicates a misunderstanding of safe sleep practices and poses a risk to the baby's safety.