A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz (4,139 grams), 21 inches long, TPR 96.6°F (35.9°C), 158, 62, jittery, pink body with bluish hands and feet, crying.
Which of the following nursing actions is of highest importance?

Choice A rationale

While infection prevention is vital, ensuring breathing function is more critical after ASP.

Choice B rationale

ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.

Choice C rationale

Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.

Choice D rationale

Voiding without pain is important, but respiratory stability takes precedence.

Choice A rationale

Retained tissue can cause postpartum hemorrhage, but with a firm uterus and no other signs of retained placenta, this is less likely the cause here.

Choice B rationale

Trauma is the most likely cause of increased bleeding in this scenario. The prolonged oxytocin induction and macrosomic infant suggest a higher risk of lacerations or uterine atony despite the firm uterus.

Choice C rationale

Thrombin disorders cause bleeding due to clotting issues. However, this patient shows signs of active bleeding and clotting, making this less likely.

Choice D rationale

Uterine atony, indicated by a soft, boggy uterus, is a common cause of postpartum hemorrhage, but in this case, the uterus is firm, so it's less likely to be the cause.