A nurse is caring for a client who is 18 hours postpartum.
Which finding should alert the nurse to the possibility of a postpartum complication?

Choice A rationale

Teaching the parents how to swaddle is important for newborn care, but it is not the priority action immediately after delivery to promote parent-infant bonding. Skin-to-skin contact is more effective in establishing an initial bond.

Choice B rationale

Positioning the infant on the client’s chest for skin-to-skin care is the priority action to promote parent-infant bonding immediately after delivery. Skin-to-skin contact helps regulate the infant’s temperature, heart rate, and breathing, and promotes bonding through physical closeness and sensory interaction.

Choice C rationale

Offering to take the newborn to the nursery so the parents may nap is not the priority action for promoting bonding immediately after delivery. While rest is important, the initial moments after birth are crucial for establishing a bond through direct contact.

Choice D rationale

Assessing the infant under the radiant warmer is important for ensuring the infant’s health, but it is not the priority action for promoting parent-infant bonding immediately after delivery. Skin-to-skin contact should be prioritized unless there are medical concerns that require immediate attention. .

Choice A rationale

Asking the client to rate her pain is important for assessing discomfort, but it does not address the immediate issue of a deviated fundus. A deviated fundus often indicates a full bladder, which can impede uterine contraction and increase the risk of postpartum hemorrhage.

Choice B rationale

Encouraging the client to perform Kegel exercises is beneficial for pelvic floor strengthening but does not address the immediate concern of a deviated fundus. The priority is to ensure the uterus can contract properly.

Choice C rationale

Assisting the client to the bathroom to void is the correct action. A full bladder can displace the uterus, preventing it from contracting effectively and increasing the risk of hemorrhage. Voiding helps the uterus return to its proper position and function.

Choice D rationale

Encouraging the client to move to the left lateral position may provide comfort but does not address the underlying issue of a full bladder causing uterine displacement.