A nurse is assisting with the care of a newborn who is 4 hr old.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

A. Terbutaline is typically used to manage preterm labor, not a contraindication for dinoprostone, which is used for labor induction.
B. FHR (Fetal Heart Rate) of 140/min with moderate variability is within normal limits and would not be a reason to withhold dinoprostone.
C. WBC count is within normal limits, indicating no infection, thus not a contraindication for dinoprostone.
D. Lesions noted on vaginal introitus and labia majora could indicate an active Herpes simplex virus infection, which is a contraindication for vaginal delivery due to the risk of neonatal infection.
E. Breech presentation is a concern for delivery method but does not contraindicate the use of dinoprostone for labor induction.

A. Blood pressure 136/86 mm Hg
- The blood pressure reading is slightly elevated but not critically high. Postpartum hypertension can be a concern, but this level does not indicate an immediate risk.
- This reading is consistent with the earlier measurement, suggesting stability.
- Immediate follow-up is not required unless there is a significant increase or additional symptoms are present.
B. Peripheral edema 2+ bilateral lower extremities
- Edema is common in the postpartum period due to fluid shifts and should resolve naturally.
- The consistent 2+ rating indicates no acute change.
- Monitoring is appropriate, but it does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
C. Lateral deviation of the uterus
- A laterally deviated uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention.
- The deviation from the firm, midline position noted earlier could suggest an underlying issue that needs immediate investigation.
- This finding could lead to complications if not addressed promptly.
D. Breasts soft
- Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding.
- There is no change from the earlier assessment.
- This does not require immediate follow-up as it is a normal finding.
E. Pain rating of 3 on a scale of 0 to 10
- A pain rating of 3 is mild and manageable, especially considering it was 2 earlier.
- This slight increase in pain is expected and can be monitored with routine care.
- It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
F. Uterine tone soft
- A soft uterine tone postpartum can indicate uterine atony, which can lead to hemorrhage.
- The change from a previously firm uterus to a soft one is concerning.
- Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
G. Large amount of lochia rubra
- A large amount of lochia rubra can be a sign of excessive bleeding.
- The increase from a moderate amount earlier to a large amount could indicate a hemorrhagic complication.
- This finding requires immediate follow-up to assess for postpartum hemorrhage.
H. Deep tendon reflexes 1+
- A deep tendon reflex of 1+ is considered within normal limits.
- There has been no change from the earlier assessment.
- This finding does not require immediate follow-up as it is a normal finding.