A nurse is admitting a term newborn to the nursery following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

Choice A:

Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.

Choice B:

Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.

Choice C:

Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.

Choice D:

Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.

Choice E:

Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.

Choice A reason:

This statement does not indicate inhibition of parental attachment. The client may have prior experience or knowledge of bathing a newborn and may not need the demonstration. The nurse should respect the client's autonomy and confidence in this skill.

Choice B reason:

This statement does not indicate inhibition of parental attachment. The client may be exhausted from the labor and delivery process and may need some rest to recover. The nurse should support the client's request and ensure that the newborn is well cared for in the nursery.

Choice C reason:

This statement indicates inhibition of parental attachment. The client expresses dissatisfaction with the newborn's appearance and implies that the newborn is not attractive enough. The nurse should explore the client's feelings and expectations about the newborn and provide reassurance and education about normal variations in newborn features.

Choice D reason:

This statement does not indicate inhibition of parental attachment. The client recognizes a family resemblance in the newborn and expresses a positive connection with the newborn and the partner. The nurse should acknowledge the client's observation and encourage further bonding with the newborn.