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?

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.

Choice A rationale

Hypertension is not a characteristic finding of hyperemesis gravidarum, which primarily affects fluid balance and nutritional status.

Choice B rationale

Dry mucous membranes are a sign of dehydration, commonly associated with hyperemesis gravidarum due to excessive vomiting.

Choice C rationale

Tachycardia can result from dehydration and electrolyte imbalances seen in hyperemesis gravidarum.

Choice D rationale

Poor skin turgor indicates dehydration, a common symptom of hyperemesis gravidarum.

Choice E rationale

Polyuria is not typical in hyperemesis gravidarum; the condition usually leads to dehydration, reducing urine output.