A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:

A) First baby, day of delivery, fundus 2 cm above umbilicus deviated to left:
This is the most urgent situation. The fundus should typically be at the level of the umbilicus on the first postpartum day. A fundus that is 2 cm above the umbilicus and deviated to the left may indicate that the bladder is full, which can cause uterine displacement. This is a priority because if the bladder is not emptied, it could lead to uterine atony or hemorrhage. The nurse should first assess the bladder and encourage the client to void, or catheterize if needed, to correct the deviation.

B) Second baby, first postpartum day, hypoactive bowel sounds all quadrants:
Hypoactive bowel sounds on the first postpartum day can be expected, particularly after a cesarean section or due to the effects of medications such as opioids. While this finding should be monitored, it is not as urgent as a potential issue with uterine positioning that could affect bleeding or uterine tone.

C) Third baby, first postpartum day, 3 cm diastasis recti abdominis:
Diastasis recti abdominis, where the abdominal muscles separate, is a common finding postpartum, especially after multiple pregnancies. While it may cause discomfort, it is generally not an immediate concern unless there is significant pain or other complications. It can be addressed with physical therapy over time.

D) Second baby, third day post-cesarean, moderate lochia serosa:
Lochia serosa is the expected discharge 3 days postpartum after a cesarean. Moderate lochia serosa is normal at this stage and does not indicate an immediate problem. The nurse should continue to monitor the lochia, but this is not as urgent as addressing the possible uterine displacement and bladder issue in Option A.

A) Don't do anything, this is a normal finding:
While it's true that acrocyanosis (bluish-purple discoloration of the hands and feet) can be a normal finding in the first 24-48 hours of life due to immature circulation, it’s important to assess the severity of the condition and rule out more serious causes. Just ignoring it without assessing the infant’s oxygenation status could lead to missing a potential respiratory issue.

B) Check the infant's O2 sat:
The most appropriate action is to assess the infant’s oxygen saturation levels. Acrocyanosis is typically benign and resolves on its own, but persistent cyanosis or a drop in oxygen saturation could indicate a more serious issue, such as respiratory distress or congenital heart disease. A pulse oximeter is a non-invasive tool that can help determine whether the infant’s oxygenation is adequate. This would help guide further clinical decisions.
C) Call the MD for referral:
Calling the doctor should only be considered if the baby’s oxygen saturation levels are low, or if other concerning symptoms (like poor feeding, lethargy, or significant difficulty breathing) are present. If the O2 saturation is normal, there’s no immediate need for referral. The key is to assess first before escalating to the provider.

D) Put socks and mittens on the infant to keep them warm:
Although providing warmth can help with maintaining body temperature, simply putting socks and mittens on the baby is not sufficient to rule out respiratory issues or other causes of cyanosis. If the infant’s oxygen saturation is normal and the baby is otherwise stable, this may be appropriate. However, checking the O2 saturation first is the correct step to ensure that no underlying respiratory problems are contributing to the cyanosis.