The nurse is caring for a large-for-gestational-age infant born to a client with diabetes mellitus.
What is the priority when assessing this infant?

Choice A rationale

While the amount of blood loss is critical for determining the severity of the hemorrhage and the need for immediate treatment, it is not the priority assessment before administering methylergonovine. The amount of blood loss determines the need for the drug, but the blood pressure determines its safety before administration. Methylergonovine is a potent vasoconstrictor and must be used cautiously in clients with elevated blood pressure to prevent hypertensive crisis or stroke.

Choice B rationale

Methylergonovine is an ergot alkaloid that acts as a potent vasoconstrictor and uterine stimulant. Its primary side effect and contraindication are hypertension and preeclampsia. Because the drug dramatically increases systemic vascular resistance, it can cause a sudden, severe elevation in blood pressure. Therefore, checking the blood pressure is the priority assessment to ensure the client's pressure is within safe limits before administration, preventing potential complications like stroke.

Choice C rationale

Although a change in the level of consciousness (LOC) could indicate hypovolemic shock from severe blood loss or a hypertensive emergency, it is a secondary finding. The primary, direct, and modifiable risk associated with methylergonovine administration is its potential to cause acute, severe hypertension. Checking the client's baseline blood pressure (Choice B) is the specific, essential safety check before administering this vasoconstrictive medication.

Choice D rationale

The uterine tone or atony is the indication for the medication; the client is already diagnosed with uterine atony (flaccid uterus) causing the hemorrhage. The medication's purpose is to contract the uterus (increase tone). The priority before administration, however, is to assess the client for contraindications or serious adverse reaction risks. The potent vasoconstrictive effect on peripheral arteries makes blood pressure (Choice B) the most critical pre-administration safety assessment.

Choice A rationale

Uterine atony is the leading cause of postpartum hemorrhage, resulting in significant blood loss and hypovolemia. Increasing intravenous fluid replacement with crystalloid solutions (e.g., normal saline or lactated Ringer's) is critical to restoring circulating blood volume, maintaining hemodynamic stability, and preventing hypovolemic shock.

Choice B rationale

A full bladder can displace the uterus and impede its ability to contract effectively, contributing to or worsening uterine atony. Inserting an indwelling urinary catheter (Foley catheter) ensures continuous bladder drainage and decompression, allowing the uterus to move into its proper place and contract more effectively.

Choice C rationale

Monitoring deep tendon reflexes (DTRs) is primarily an assessment for magnesium sulfate toxicity in clients being treated for preeclampsia or eclampsia. While relevant in those specific conditions, it is not a direct intervention for managing the immediate effects or cause of postpartum hemorrhage due to uterine atony. Normal DTR response is 2+.

Choice D rationale

Quantifying blood loss is essential for determining the severity of the hemorrhage and the efficacy of interventions. Initiating a peri-pad count and accurately weighing the pads provides a reliable, though often underestimated, measure of blood loss, guiding the need for additional fluids, blood products, or uterotonic medications.

Choice E rationale

Uterine atony is a failure of the uterine muscle to contract and compress the blood vessels at the placental site. Performing a fundal massage stimulates the myometrium to contract, thereby physically compressing the vessels and activating the natural physiological mechanisms to stop the bleeding; this is a primary, initial intervention.

Choice F rationale

Tocolytic therapy, such as terbutaline or nifedipine, works by relaxing the uterine muscle, which is used to stop preterm labor. In the context of uterine atony, the goal is to contract the uterus, so administering tocolytic therapy would be contraindicated as it would worsen the atony and accelerate blood loss.