The nurse is caring for a macrosomic newborn of a woman diagnosed with gestational diabetes immediately after birth.
What assessment findings can the nurse anticipate? (Select All that Apply.)

Choice A rationale

Nalbuphine (Nubain) is an opioid agonist-antagonist analgesic frequently used for pain relief during labor. Its pharmacological action involves κ-receptor agonism and μ-receptor partial antagonism. While opioids can affect the cardiovascular system, bradycardia (a slow heart rate, <110 bpm in a fetus) is less common than tachycardia or minimal fetal heart rate variability. Bradycardia is a known adverse effect of some medications, but respiratory depression is the primary, most significant opioid-related risk.

Choice B rationale

Nalbuphine generally does not cause hypertension (high blood pressure). In fact, common cardiovascular side effects of opioids can include orthostatic hypotension due to peripheral vasodilation and histamine release, though its overall impact on maternal blood pressure is usually minimal or transient. The most critical adverse reaction concerning patient safety, especially in the neonate after delivery, relates to respiratory function due to medullary effects.

Choice C rationale

Respiratory depression is the most significant adverse reaction associated with nalbuphine, as with other opioids, due to its depressant effect on the respiratory center in the brainstem (medulla). It decreases the sensitivity of the respiratory center to carbon dioxide, leading to a reduced rate and depth of respiration. This risk is present for the mother and can cross the placenta, potentially causing neonatal respiratory depression, especially if administered close to delivery.

Choice D rationale

Hyperglycemia (elevated blood glucose) is not a commonly reported or primary adverse effect of nalbuphine. Opioids can sometimes affect glucose metabolism, but the more significant and clinically relevant adverse effects relate to the central nervous system and respiratory function. Nalbuphine's primary mechanism of action doesn't directly involve the pancreatic hormones or glucose regulation pathways in a clinically significant manner leading to hyperglycemia.

Choice A rationale

Uterine atony, defined as the failure of the myometrial muscle fibers to contract effectively after placental separation, is the most common cause of postpartum hemorrhage (PPH), accounting for approximately 70 to 80 percent of cases. This lack of contraction prevents the mechanical compression of blood vessels at the placental site, leading to rapid and profuse blood loss into the uterine cavity.

Choice B rationale

Uterine inversion is the rare turning inside out of the uterus. While it causes profuse bleeding and is a life-threatening emergency, its incidence is very low (around 1 in 3000 to 20,000 deliveries), making it statistically less likely than uterine atony to be the cause of profuse bleeding in an unspecified client in the immediate postbirth period.

Choice C rationale

Vaginal lacerations are a common cause of postpartum bleeding, but typically the bleeding is described as a steady trickle of bright red blood, often despite a firm uterus. While it can be profuse, uterine atony typically results in a rapid gush or steady flow of blood associated with a boggy fundus, making it the more likely primary cause for generalized "profuse bleeding.”.

Choice D rationale

A vaginal hematoma involves a collection of blood in the connective tissue spaces and usually presents with pain and a mass, with the amount of external bleeding often being minimal or absent. The blood is concealed within the tissue space. Therefore, a hematoma is an unlikely cause of externally visible, profuse, hemorrhage.

Choice E rationale

Retained placental fragments also cause PPH, often through preventing the uterus from fully contracting (secondary atony). While a significant cause, fragments are often associated with bleeding that is intermittent or delayed, or bleeding that begins after the first hour. Primary uterine atony remains the most frequent etiology of profuse bleeding immediately postbirth.