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This is not correct because the umbilical cord does not need antibiotic ointment to prevent infection. It should be kept clean and dry until it falls off naturally.

This is not correct because the tear ducts are not affected by vaginal bacteria. They are small tubes that drain tears from the eyes to the nose.

This is not correct because the urethra is not a common site of infection for newborns. The urethra is the tube that carries urine from the bladder to the outside of the body.

This is not correct because administering oxytocin is not the first action to take. Oxytocin is a medication that can also help the uterus contract, but it should be given after assessing the uterine tone and bleeding.

This is not correct because observing for pooling of blood under the buttocks is not a priority action. It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.

This is not correct because checking the client’s blood pressure is not the first action to take. Blood pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain normal until a significant amount of blood is lost.

This is not correct because lochia alba is the last stage of lochia. It is whitish or yellowish-white in color and contains fewer red blood cells and more leukocytes, epithelial cells, cholesterol, fat, mucus, and microorganisms. It lasts from the second through the third to sixth weeks after delivery.

This is not correct because there is no such thing as lochia normal. Lochia has three stages: lochia rubra, lochia serosa and lochia alba.

This is not correct because lochia serosa is the second stage of lochia. It is brownish or pink in color and contains serous exudate, erythrocytes, leukocytes, cervical mucus, and microorganisms. It lasts for 4 to 12 days after delivery.

Thisis not correct because determining if the mother's milk is coming in is not the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery. Milk production usually begins around 48 to 72 hours after delivery and is influenced by hormonal changes, breastfeeding frequency, and maternal health. Although breastfeeding support is important for postpartum care, it is not a priority over checking for postpartum hemorrhage.

This is not correct because monitoring the mother's blood pressure to note any elevations is not the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery. Elevated blood pressure can indicate gestational hypertension or preeclampsia, which are serious conditions that can affect postpartum women. However, these conditions are more likely to cause symptoms such as headache, blurred vision, epigastric pain, and proteinuria⁴.
Moreover, blood pressure may not be a sensitive indicator of blood loss and may remain normal until a significant amount of blood is lost¹.

This is not correct because answering questions the new parents may have is not the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery. Although providing education and support to the new parents is an essential part of postpartum care, it is not a priority over checking

for postpartum hemorrhage. The new parents may have questions about infant care, feeding, contraception, recovery, and other topics that can be addressed during the postpartum period.

This is not correct because mucus draining from the nose is not a symptom of respiratory distress in newborns. It is normal for newborns to have some mucus in their nose and mouth after birth, which can be cleared by suctioning or wiping.
Mucus drainage does not interfere with breathing unless it is excessive or thick.

This is not correct because cyanosis of the hands and feet is not a symptom of respiratory distress in newborns. It is normal for newborns to have bluish discoloration of their hands and feet, called acrocyanosis, for the first few days after birth. This is due to immature circulation and does not indicate a lack of oxygen. Cyanosis of the central parts of the body, such as the face, lips, and tongue, is more concerning and should be reported³.

This is not correct because irregular heart rate is not a symptom of respiratory distress in newborns. It is normal for newborns to have some variations in their heart rate, especially during sleep cycles. The normal heart rate range for newborns is 100 to 160 beats per minute. A heart rate that is too fast (tachycardia) or too slow (bradycardia) may indicate a problem with the heart or other organs.

This is not correct because nevus flammeus is a type of birthmark that is also known as port-wine stain. It is a flat, red, or purple patch of skin that can appear anywhere on the body, but often on the face. It is caused by abnormal blood vessels in the skin and does not go away over time³.

This is not correct because the molding is the temporary change in the shape of the head due to pressure during delivery. It does not cause swelling or bruising and usually resolves within a few days.

This is not correct because caput succedaneum is a type of swelling that affects the scalp and crosses the suture line. It is caused by fluid accumulation under the scalp due to pressure during delivery. It usually appears at birth and goes away within a few days.

This is not correct because gestational hypertension is not a risk factor for postpartum hemorrhage. It is a condition that causes high blood pressure during pregnancy and can lead to complications such as preeclampsia, eclampsia, and placental abruption³.

This is not correct because small for gestational age newborn is not a risk factor for postpartum hemorrhage. It is a condition that indicates that the baby's growth was restricted in the womb and weighs less than 90% of other babies of the same gestational age. It can be caused by maternal factors, placental factors, or fetal factors⁴.

This is not correct because a two-vessel umbilical cord is not a risk factor for postpartum hemorrhage. It is a condition that occurs when the umbilical cord has only one artery and one vein instead of the normal two arteries and one vein. It can be associated with congenital anomalies, intrauterine growth restriction, and stillbirth.

This is not correct because drying the infant off and covering the head is not the first action to take. Drying and covering the infant helps prevent heat loss and hypothermia, which are important for newborn care. However, this should be done after clearing the respiratory tract.

This is not correct because stimulating the infant to cry is not the first action to take. Stimulating the infant to cry can help expand the lungs and improve oxygenation, which is also important for newborn care. However, this should be done after clearing the respiratory tract.

This is not correct because clamping the umbilical cord is not the first action to take. Clamping and cutting the umbilical cord separates the baby from the placenta, which is no longer needed after birth. However, this should be done after clearing the respiratory tract.

This is not correct because the change in lochia from red to white is not a sign of postpartum complication. Lochia is the vaginal discharge that occurs after childbirth. It changes color and amount over time, from red to pink to brown to yellow to white. This is a normal process of healing and does not indicate a problem unless the lochia is foul-smelling, heavy, or contains large clots.

This is not correct because fatigue and irritability are not signs of postpartum complications. Fatigue and irritability are common feelings after childbirth due to hormonal changes, sleep deprivation, physical recovery, and emotional adjustment. They do not necessarily indicate a problem unless they are severe or persistent and interfere with daily functioning or bonding with the baby.

This is not correct because contractions are not signs of postpartum complication. Contractions are normal after childbirth and help the uterus shrink back to its pre-pregnancy size. They are usually mild and subside within a few days. They may be more intense during breastfeeding due to the release of oxytocin, which stimulates uterine contractions.

This is not correct because initiating measures that encourage voiding is not the appropriate intervention for a soft, boggy uterus. A full bladder can interfere with uterine contractions and cause bleeding, so it is important to empty the bladder after delivery. However, this should be done after massaging the fundus.

This is not correct because positioning the patient flat is not the appropriate intervention for a soft, boggy uterus. Positioning the patient flat can increase blood loss and reduce venous return. The patient should be positioned with the head slightly elevated and the legs flexed to improve blood circulation and prevent shock.

This is not correct because notifying the doctor is not the first intervention for a soft, boggy uterus. Notifying the doctor is important if bleeding persists or worsens despite massaging the fundus. The doctor may order medications or other treatments to stop the bleeding and prevent complications.