A nurse is caring for a female client who is primigravida at 30 weeks of gestation in the antepartum unit.

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Choice A rationale

Transient circumoral cyanosis, a bluish discoloration around the mouth, can be a normal finding in the immediate newborn period, especially during periods of crying or temperature instability. It is often related to immature peripheral circulation and typically resolves as the newborn's circulatory system adapts to extrauterine life, without requiring intervention.

Choice B rationale

Transient strabismus, or crossed eyes, is a common and normal finding in newborns due to immature neuromuscular control of eye movements. The newborn's eye muscles are still developing coordination, and occasional misalignment is expected. This usually resolves spontaneously by 3 to 4 months of age as vision matures.

Choice C rationale

Caput succedaneum, a localized soft tissue edema of the scalp, is a common finding in newborns after vaginal birth. It results from pressure on the presenting part of the head during labor. It crosses suture lines and typically resolves within a few days, representing a benign finding that does not require medical intervention.

Choice D rationale

Generalized petechiae, which are small, pinpoint hemorrhages, are an abnormal finding in a 1-hour-old newborn and warrant immediate reporting to the provider. While scattered petechiae over the presenting part may occur with a difficult delivery, generalized petechiae can indicate a coagulation disorder, infection, or other serious underlying pathological condition requiring prompt evaluation and intervention.

The nurse should first monitor the client’s fundal tone followed by the client’s heart rate.

Rationale for correct answers
Fundal tone is the primary indicator of uterine contractility. A boggy fundus that does not firm with massage indicates uterine atony, the most common cause of postpartum hemorrhage (PPH). Effective uterine contraction compresses uterine blood vessels to reduce bleeding. Monitoring fundal tone allows early identification of hemorrhage risk. Heart rate is a sensitive early sign of hypovolemia; a rising heart rate (tachycardia above 100 beats/min) reflects compensatory response to blood loss before blood pressure drops. Normal adult heart rate ranges from 60 to 100 beats/min; an increase indicates circulatory stress.

Rationale for incorrect answers
Bruising to perineal area (A) is important but secondary; it does not directly assess bleeding severity or uterine status. Pain level (C) is subjective and can be influenced by many factors; it does not reliably indicate hemorrhage. Uterine height (D) measures fundal location but does not assess firmness or tone, which are critical for detecting atony. Temperature (B) changes are not immediate indicators of bleeding. Pain level (C) and uterine height (D) similarly lack specificity for hemorrhage assessment compared to fundal tone and heart rate.

Take home points

• Fundal tone assessment is critical for early detection of uterine atony causing postpartum hemorrhage.
• Tachycardia is an early physiological sign of hypovolemia and should be closely monitored.
• Perineal bruising and pain are secondary findings and less specific to hemorrhage severity.
• Uterine height and temperature changes do not reliably indicate acute hemorrhage status.