Choice A rationale: A postmature newborn, or one born after 42 weeks of gestation, is likely to exhibit cracked, peeling skin due to the prolonged exposure to amniotic fluid and the absence of vernix. This makes Choice A the correct answer, as it reflects the expected findings for a postmature newborn.

Choice B rationale: Abundant lanugo is typically seen in preterm infants, not postmature infants. Lanugo is a fine, downy hair that covers the fetus and usually disappears by 37 weeks of gestation. Therefore, Choice B is not an expected finding for a postmature newborn.

Choice C rationale: Short, soft fingernails are characteristic of preterm infants. In postmature infants, fingernails are generally long and may extend beyond the fingertips due to prolonged gestation. This makes Choice C an incorrect answer for the expected findings of a postmature newborn.

Choice D rationale: Abundant vernix is typically seen in preterm and term infants. Vernix is a white, cheesy substance that covers the fetal skin to protect it from amniotic fluid. Postmature infants usually have minimal to no vernix present, as it has already been absorbed. Therefore, Choice D is not an expected finding for a postmature newborn.

Choice A rationale:
Perineal pad clots are not the greatest risk for this patient. While it’s important to monitor the amount and type of lochia, the nurse’s notes indicate that the patient has a moderate amount of lochia rubra, which is normal within the first few days postpartum. Large clots could indicate a problem such as a retained placental fragment, but this is not mentioned in
the scenario.
Choice B rationale:
Pelvic pain is a common complaint after childbirth due to uterine contractions, especially during breastfeeding, and usually resolves within a few days. The patient’s pain is rated as 4 on a scale of 0 to 10, which is considered moderate. While it’s important to manage the patient’s pain, it’s not the greatest risk in this scenario.
Choice C rationale:
A boggy uterus poses the greatest risk for this patient. A boggy or soft uterus indicates uterine atony, which is a lack of normal muscle tone that can lead to excessive bleeding. This is a serious condition that can lead to postpartum hemorrhage if not treated promptly. The nurse’s notes indicate that the patient’s fundus is boggy and located above the umbilicus, which is a concern. The fundus should be firm and gradually descend into the pelvis within the first few days postpartum.
Choice D rationale:
Breast engorgement is a common discomfort that occurs when the breasts are overly full with milk. It typically occurs within the first week postpartum as the milk supply increases. The nurse’s notes indicate that the patient’s breasts are soft, warm, and tender to touch, which is normal. While it’s important to manage the patient’s comfort, breast
engorgement is not the greatest risk in this scenario.