The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? Select all that apply.

Choice A reason:

Nevus flammeus, also known as a port-wine stain, is a flat, pink, red, or purple mark on the skin present at birth. It is a congenital vascular malformation and does not involve swelling that crosses suture lines.

Choice B reason:

Caput succedaneum is the correct diagnosis for swelling that crosses suture lines on a newborn's head, typically associated with a prolonged or difficult vaginal delivery, especially with the use of vacuum extraction.

Choice C reason:

Cephalohematoma is a collection of blood under the periosteum of the cranial bones that does not cross suture lines. It appears soon after birth and is usually caused by birth trauma.

Choice D reason:

Erythema toxicum is a common rash in newborns, presenting as red patches with small white or yellow pustules. It does not cause swelling over the head that crosses suture lines.

Choice C rationale:

The nurse should first massage the client's fundus to address the excessive vaginal bleeding. Massaging the fundus helps the uterus contract and prevents further bleeding. Excessive postpartum bleeding may indicate uterine atony, which is a leading cause of postpartum hemorrhage. The nurse should apply gentle pressure to the fundus to promote uterine contractions and reduce bleeding.

Choice A rationale:

Elevating the client's legs to a 30° angle (Trendelenburg position) is not the priority action in this situation. Fundal massage takes precedence because it directly addresses the cause of the excessive bleeding. While Trendelenburg position might be used in some situations to increase blood flow to vital organs, it is not the first-line intervention for postpartum bleeding.

Choice B rationale:

Inserting an indwelling urinary catheter is not the priority action for excessive vaginal bleeding. While monitoring urine output is essential, the immediate concern is controlling the bleeding by massaging the fundus.

Choice D rationale:

Initiating an infusion of oxytocin may be indicated if fundal massage alone is insufficient to control bleeding. However, massaging the fundus should be the first action taken to promote uterine contractions. Oxytocin can be administered afterward, if needed, under the direction of a healthcare provider.