A nurse is assessing a 1-hour-old newborn.Which of the following findings should the nurse report to the provider?

Choice A rationale

Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.

Choice B rationale

Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-circumcision healing.

Choice C rationale

Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process, not a result of urine exposure.

Choice D rationale

Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .

The nurse should prioritize monitoring the client's fundal tone followed by the client's blood pressure. Here's why:

1. Fundal Tone: The client's fundus is boggy and not firming up with massage. This is a priority concern as it indicates uterine atony, which is a major cause of postpartum hemorrhage.
2. Blood Pressure: Monitoring blood pressure is crucial as the client is experiencing heavy lochia, and a decrease in blood pressure can indicate hypovolemic shock due to blood loss.

So, the completed sentence would be:

• The nurse should first monitor the client's fundal tone followed by the client's blood pressure.

Taking care of immediate risks and stabilizing the patient is key in such cases.