A nurse is caring for an adolescent with spina bifida who is paralyzed from the waist down. Which of the following client statements should alert the nurse to the need for further education?

Choice A rationale
Evaluating the firmness of the uterus is the first action the nurse should take when a client’s blood pressure is 60/50 mm Hg after giving birth. A soft or “boggy” uterus can indicate uterine atony, a condition in which the uterus fails to contract after birth. Uterine atony can lead to significant postpartum hemorrhage, which can cause hypotension.
Choice B rationale
Oxygenating by rebreather mask may be necessary if the client shows signs of hypoxia or difficulty breathing, but it is not the first action the nurse should take.
Choice C rationale
Administering oxytocin infusion can stimulate uterine contractions and help control postpartum bleeding. However, the nurse should first assess the firmness of the uterus.
Choice D rationale
Obtaining a type and crossmatch may be necessary if the client needs a blood transfusion, but it is not the first action the nurse should take.

Choice A rationale
Erythema toxicum is a common rash seen in newborns, characterized by blotchy red spots on the skin with overlying white or yellow papules or pustules. It does not present as small white nodules on the roof of the mouth.
Choice B rationale
Mongolian spots are a type of birthmark that are flat, blue, or blue-gray. They appear at birth or in the first or second week of life. They look similar to bruises and are most often found on the buttocks or lower back, but are never found on the roof of the mouth.
Choice C rationale
Epstein pearls are small, harmless white or yellow nodules that may appear along your newborn baby’s gums or on the roof of their mouth. They are common and usually go away within three months after birth.
Choice D rationale
Milia spots are tiny white bumps that appear across a baby’s nose, chin or cheeks. Milia are common in newborns but can occur at any age. Unlike Epstein pearls, they do not appear on the roof of the mouth.