A nurse is caring for a newborn who is 70 hours old in the newborn nursery.

Exhibits

For each assessment finding, click to specify if the finding is consistent with hypoglycemia or neonatal abstinence syndrome (NAS). Each finding may support more than one disease process.

Choice A rationale

Completely saturating a perineal pad within 15 minutes indicates excessive postpartum bleeding, which is most commonly caused by uterine atony (failure of the uterus to contract effectively after delivery). Massaging the fundus stimulates uterine muscles to contract, helping to compress blood vessels at the placental site and control bleeding. This is the priority intervention to prevent further blood loss and potential hemorrhage.

Choice B rationale

Assessing vital signs is important to evaluate the extent of blood loss and the woman's hemodynamic stability. However, the immediate priority is to address the cause of the excessive bleeding by promoting uterine contraction. Vital sign assessment should follow fundal massage.

Choice C rationale

Calling the primary health care provider is necessary to report the excessive bleeding and implement further management if fundal massage is not effective. However, the nurse's immediate action should be to address the likely cause of the bleeding through fundal massage.

Choice D rationale

Initiating an intravenous (IV) infusion of Ringer's lactate solution may be necessary to restore fluid volume if significant blood loss has occurred or continues. However, the immediate priority is to stop the bleeding by promoting uterine contraction through fundal massage. IV fluids are a subsequent intervention to support hemodynamic stability.

Rationales for Each Condition

Hyperemesis Gravidarum

1. Weight loss: Excessive vomiting leads to poor nutritional intake and dehydration, causing unintended weight loss. The normal weight gain expected in the first trimester of pregnancy is around 0.5–2 kg. A weight loss of 0.9 kg in two weeks is concerning.
2. Hypotension: Dehydration due to persistent vomiting causes reduced intravascular volume, leading to low blood pressure. Normal blood pressure ranges from 90/60 mm Hg to 120/80 mm Hg. The client's 96/52 mm Hg value indicates potential volume depletion.
3. Tachycardia: Fluid loss and electrolyte imbalances increase heart rate as a compensatory mechanism to maintain perfusion. The normal heart rate ranges from 60–100 bpm, and the client's 116 bpm suggests dehydration-related tachycardia.

Cystitis

1. Dysuria: Inflammation of the bladder due to infection causes pain or burning during urination, a classic symptom of cystitis. The absence of other urinary symptoms, such as urgency or hematuria, helps differentiate cystitis from other conditions.