A nurse is assessing a newborn who is breastfed and has a weight loss of 11% at 48 hr after birth.
Which of the following findings should the nurse report to the provider?

Choice A rationale

Blood pressure should be assessed as opioid analgesics can cause hypotension, which can be detrimental to both mother and fetus during labor.

Choice B rationale

Fetal heart rate monitoring is essential as opioids can cross the placenta and potentially cause fetal bradycardia or distress, thus necessitating close monitoring.

Choice C rationale

Deep tendon reflexes are not commonly affected by opioid analgesics and therefore are not a primary assessment when administering these medications during labor.

Choice D rationale

Blood glucose levels are not typically influenced by opioid analgesics in the context of labor, so this is not a relevant assessment for this scenario.

Based on the assessment findings, the nurse identifies that the client is at greatest risk for developing:

1. Postpartum infection
2. Hemorrhage

Here's the

• Postpartum infection: The client has a history of prolonged rupture of membranes and is experiencing a moderate amount of lochia rubra, both of which increase the risk of infection. Additionally, she reports feeling weak, fatigued, and has a temperature of 38.5°C (101.3°F), which are signs of a possible infection.
• Hemorrhage: The moderate amount of lochia rubra and a boggy fundus above the umbilicus indicate that the client may be at risk for postpartum hemorrhage. The provider's prescription for administering oxytocin if needed also suggests a concern for uterine atony, which can lead to hemorrhage.