Where would the nurse expect to palpate the client's uterine fundus at this time?

Choice A rationale

Assigning all newborn care to the father does not address the mother's apparent emotional distress or promote her direct involvement, which is crucial for establishing the initial maternal-infant bond. The priority is to explore the mother's feelings and underlying reasons for her withdrawal to facilitate a healthy attachment and provide appropriate support.

Choice B rationale

The initial priority is a therapeutic assessment to understand the mother's perspective. Avoiding eye contact, hesitating to hold the infant, and expressing frustration are behaviors suggestive of anxiety, fear, or potential postpartum blues. Exploring these feelings first, with a nonjudgmental approach, provides the foundation for building trust and planning further necessary interventions.

Choice C rationale

While documentation and social service consultation may be necessary later, the immediate step should be a direct, nurse-led intervention to address the risk of poor bonding and potential feeding complications (like 5 hours since last attempt) by engaging with the mother. Immediate psychosocial support is a nursing responsibility before a referral.

Choice D rationale

Taking the newborn to the nursery is a separating intervention that should be avoided unless the infant's safety is compromised. The goal is to keep the dyad together and facilitate bonding. Removing the baby validates the mother's avoidance and hinders the development of her maternal confidence and attachment to the infant. —.

Choice A rationale

The uterus is generally no longer palpable abdominally by about 10 to 14 days postpartum, as it descends back into the true pelvis. Therefore, a non-palpable uterus by week 2 (14 days) is often a normal finding, not one that strongly suggests subinvolution, which is a slower-than-expected return to the non-pregnant state.

Choice B rationale

Lochia serosa (pinkish-brown discharge) typically appears around day 4 or 5 and may last until about the tenth day. Its presence on day 5 is within the expected timeline of normal involution. Subinvolution is often characterized by prolonged or excessive lochia (rubra or serosa) beyond the normal time frame.

Choice C rationale

The fundus is typically located 1-2 cm below the umbilicus by 24 hours postpartum and descends approximately 1 fingerbreadth (1 cm) per day. A fundus 2 cm below the umbilicus on day 3 is consistent with the expected rate of involution, suggesting a normal progression, not subinvolution.

Choice D rationale

The uterus is typically at or below the symphysis pubis and no longer palpable abdominally by day 10. A uterus palpable above the umbilicus on day 7 indicates that the rate of descent is slower than expected (it should be much lower), which is the hallmark sign of subinvolution. .