A baby is in the NICU whose mother was addicted to heroin during the pregnancy. Which of the following nursing actions would be appropriate?

Choice A rationale

A soft fundus indicates uterine atony, an abnormal finding requiring immediate intervention. This teaching would lead to improper patient monitoring of complications such as hemorrhage.

Choice B rationale

Clots as large as a golf ball are not considered normal and may signal uterine atony or retained placental fragments, which necessitate medical intervention for hemorrhage risk.

Choice C rationale

Decreased brownish-red lochia may reflect normal postpartum changes as it progresses to serosa and alba but is not typically an indicator of complications.

Choice D rationale

Increased lochia or a return to bright red bleeding signals potential complications like subinvolution or late postpartum hemorrhage, which demand prompt medical attention.

Choice A rationale

Keeping the infant in the mother’s room without further evaluation increases the risk of missed complications like hypoglycemia. Monitoring and interventions are crucial for infants at risk due to macrosomia or difficult delivery.

Choice B rationale

Immediate nursery transfer without specific monitoring or intervention overlooks the infant’s risk for hypoglycemia and its symptoms, such as jitteriness or poor feeding. Further evaluation is more appropriate.

Choice C rationale

Macrosomic infants are at higher risk for hypoglycemia due to increased insulin levels post-birth. Frequent glucose monitoring and vigilance for signs like jitteriness or lethargy are crucial for timely intervention.

Choice D rationale

While gestational age assessment confirms LGA status, it does not address the immediate risk of hypoglycemia. Focus should remain on monitoring and stabilizing glucose levels in at-risk macrosomic infants.