A nurse is caring for a client who is 12 hours postpartum and has a fourth-degree laceration of the perineum. The nurse should take which of the following actions?

Breast development is a normal part of fetal and neonatal growth. It occurs in stages, starting before birth and continuing during puberty and adulthood. Breast development is influenced by hormones, such as estrogen and progesterone, that are produced by the ovaries or the placenta¹².
Breast development in newborns can vary depending on the gestational age, sex, weight, and exposure to maternal hormones. Some newborns may have palpable breast tissue at birth, while others may develop it later in the first weeks of life. Some newborns may also secrete milk from their breasts, which is called witch's milk or neonatal galactorrhea. This is a harmless and temporary phenomenon that usually resolves within a few weeks without treatment³⁴.
The degree of breast development in newborns can be assessed by using a scoring system that ranges from 0 to 5, based on the size of the areola (the dark area around the nipple) and the presence of a bud (a small lump of glandular tissue under the areola). The scoring system is as follows³:
- Score 0: No breast tissue; flat areola with no bud
- Score 1: Breast tissue < 5 mm; flat areola with no bud
- Score 2: Breast tissue 5 to 10 mm; flat areola with no bud
- Score 3: Breast tissue > 10 mm; raised areola with no bud
- Score 4: Breast tissue > 10 mm; raised areola with bud
- Score 5: Breast tissue > 10 mm; raised areola with large bud
The average score for term newborns is 2.5 for girls and 2.0 for boys. The score tends to be higher for heavier babies and lower for lighter babies. The score also tends to be higher for babies who were exposed to higher levels of maternal hormones during pregnancy, such as those whose mothers had diabetes, preeclampsia, or multiple gestation³⁴.
A score of 0 indicates that there is no breast tissue at all, and the areola is flat with no bud. This finding can indicate preterm gestational age, as breast development usually starts before birth and progresses with increasing gestational age. Preterm newborns may have delayed or incomplete breast development due to insufficient exposure to maternal hormones or immature development of their own hormonal system³⁵.
Therefore, the nurse should identify this finding as indicating preterm gestational age and monitor the newborn for any other signs of prematurity, such as low birth weight, small head size, thin skin, low body temperature, respiratory distress, or feeding difficulties. The nurse should also provide appropriate care and support to the newborn and the parents according to the hospital protocol³⁵.

- b) Ambiguous secondary sex characteristics are physical features that do not clearly match the typical male or female pattern, such as genitalia, hair distribution, or voice pitch. They can be caused by genetic disorders, hormonal imbalances, or environmental influences. Ambiguous secondary sex characteristics do not affect breast development in newborns, as breast tissue is present in both sexes and is influenced by maternal hormones rather than sex hormones¹ .
- c) Decreased maternal hormones during pregnancy can affect breast development in newborns, but not in the way described. Decreased maternal hormones during pregnancy can cause lower breast scores in newborns, as they may have less stimulation of their breast tissue from the placenta. However, this does not mean that they have no breast tissue at all or a flat areola with no bud. They may still have some degree of breast development depending on their gestational age, sex, weight, and exposure to their own hormones³⁴.
- d) Congenital anomaly is a term that refers to any structural or functional abnormality that is present at birth. Congenital anomalies can affect any part of the body and can have various causes, such as genetic mutations, chromosomal abnormalities, infections, drugs, or environmental factors. Congenital anomalies can affect breast development in newborns, but not in the way described. Congenital anomalies that affect breast development in newborns usually cause abnormal or absent nipples or breasts, such as nipple hypoplasia (underdeveloped nipples), athelia (absence of nipples), amastia (absence of breasts), or polymastia (extra breasts). These anomalies do not cause a flat areola with no bud .

Heart rate is one of the vital signs that reflects the health and well-being of a newborn. It is measured by counting the number of heart beats per minute, either by listening to the chest with a stethoscope or by feeling the pulse at the wrist, elbow, or groin. Heart rate can vary depending on the newborn's activity level, temperature, and emotional state¹.
The normal range for heart rate in full-term newborns is 120 to 160 beats per minute. The heart rate may be slightly higher or lower depending on the newborn's age, weight, and gestational age. For example, premature newborns may have a higher heart rate than term newborns, and heavier newborns may have a lower heart rate than lighter newborns¹².
A heart rate that is too high (tachycardia) or too low (bradycardia) can indicate a problem with the newborn's heart function, oxygenation, or circulation. Some of the possible causes of abnormal heart rate in newborns are:

- Congenital heart defects: structural abnormalities of the heart that are present at birth and affect the blood flow through the heart and the body. They can cause cyanosis (bluish skin color), murmur (abnormal heart sound), poor feeding, or failure to thrive¹³.
- Arrhythmias: irregular or abnormal heart rhythms that can affect the electrical impulses that control the heartbeat. They can cause palpitations (feeling of skipped or extra beats), dizziness, fainting, or cardiac arrest¹³.
- Hypoxia: lack of oxygen in the blood or tissues that can affect the brain and other organs. It can be caused by respiratory distress, anemia, infection, or birth asphyxia. It can cause bradycardia, apnea (pauses in breathing), seizures, or coma¹⁴.
- Hypothermia: low body temperature that can affect the metabolism and organ function. It can be caused by exposure to cold environment, infection, or prematurity. It can cause bradycardia, lethargy, poor feeding, or hypoglycemia (low blood sugar)¹⁴.
- Sepsis: severe infection that can affect the whole body and cause inflammation and organ damage. It can be caused by bacteria, viruses, fungi, or parasites that enter the bloodstream from the mother, the umbilical cord, or the environment. It can cause tachycardia, fever, chills, poor feeding, or shock¹⁴.
Therefore, the nurse should report a heart rate of 72/min to the provider as an abnormal finding and monitor the newborn for any other signs of distress or illness. The provider may order further tests or treatments to determine the cause and severity of the low heart rate and prevent any complications.

The other findings are not findings that the nurse should report to the provider because they are within the
normal range for full-term newborns:
- a) Respiratory rate 55/min is within the normal range for respiratory rate in full-term newborns. The normal range for respiratory rate in full-term newborns is 40 to 60 breaths per minute. The respiratory rate may vary depending on the newborn's activity level, temperature and emotional state¹².
- b) Blood pressure 80/50 mm Hg is within the normal range for blood pressure in full-term newborns. The normal range for blood pressure in full-term newborns is 65 to 95 mm Hg for systolic pressure (the top number) and 30 to 60 mm Hg for diastolic pressure (the bottom number). The blood pressure may vary depending on the newborn's age, weight, and gestational age¹².
- c) Temperature 36.5°C (97.7°F) is within the normal range for temperature in full-term newborns. The normal range for temperature in full-term newborns is 36.5°C to 37.5°C (97.7°F to 99.5°F). The temperature may vary depending on the newborn's activity level, clothing, and environment¹².