A nurse is caring for a newborn 1 hour following birth in the emergency unit.

Exhibits

Select the 5 findings the nurse should report to the provider.

Choice A rationale

Assessing the client's blood pressure can help determine if there is a significant loss of blood and consequent hypotension. However, it is not the immediate first action to manage heavy bleeding postpartum.

Choice B rationale

Assessing the bladder for distention is crucial as a full bladder can interfere with uterine contraction, potentially leading to increased bleeding. But, it isn't the first priority compared to addressing the immediate bleeding.

Choice C rationale

Massaging the client's fundus is the priority action in this case. It helps to contract the uterus, thereby reducing bleeding. Uterine atony is the most common cause of postpartum hemorrhage, and fundal massage is the first intervention to manage it.

Choice D rationale

Preparing to administer a prescription may be necessary, especially if uterotonics are required. However, this is a subsequent step after attempting to control the bleeding through fundal massage.

Choice A rationale

Severe nausea and vomiting, known as hyperemesis gravidarum, are more commonly associated with high levels of human chorionic gonadotropin (hCG) and are not specific to ectopic pregnancy.

Choice B rationale

While vaginal bleeding can occur in an ectopic pregnancy, it is usually not a large amount. The bleeding in ectopic pregnancy tends to be light and irregular.

Choice C rationale

Uterine enlargement greater than expected for gestational age is typically associated with conditions like molar pregnancy, not ectopic pregnancy, as the pregnancy is located outside the uterus.

Choice D rationale

Unilateral, cramp-like abdominal pain is a classic symptom of ectopic pregnancy as the fertilized egg implants outside the uterus, most commonly in a fallopian tube, causing localized pain.