A nurse is caring for a term newborn who is 48 hr old

Exhibits

The nurse assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

A. Painful intercourse: Painful intercourse can have various causes, but it is not typically associated with serious complications related to oral contraceptives. It may be addressed with the healthcare provider during a routine follow-up.

B. Vaginal itching: Vaginal itching may be due to various reasons, including infections, but it is not typically a direct side effect of oral contraceptives. However, if the itching is persistent or severe, the client should report it to the provider for appropriate evaluation.

C. Persistent headaches: Persistent headaches can be a concerning side effect associated with the use of oral contraceptives. It may indicate an increased risk of vascular events, such as stroke or thrombosis. Clients experiencing persistent headaches while on oral contraceptives should report this symptom to the healthcare provider immediately for further evaluation.

D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives, and it is not typically an emergency or a sign of serious complications. However, if the breast tenderness is severe or associated with other concerning symptoms, the client should contact the provider for guidance.

A. The client urinates 30 ml/hr

Effective voiding after the removal of a urinary catheter involves the ability to produce an adequate amount of urine. A urine output of 30 ml per hour is within the normal range, indicating that the client is passing urine consistently, which is a positive sign of bladder function.

B. The uterine fundus is 2 cm above the umbilicus: The position of the uterine fundus is related to postpartum uterine involution and is not a direct indicator of effective voiding. It is more relevant to assessing the progress of the uterus returning to its pre-pregnancy state.

C. The bladder is distended upon palpation: A distended bladder is a sign of urinary retention, not effective voiding. If the bladder is distended, it indicates that the client may not be emptying the bladder properly.

D. The client does not feel the urge to urinate: Lack of urge to urinate could be a sign of urinary retention or impaired bladder function. A normal and healthy bladder function includes the sensation of the urge to void when the bladder is filling.