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Cyanosis of the hands and feet: Peripheral cyanosis, or acrocyanosis, is common in newborns during the first 24 hours of life and generally resolves as circulation stabilizes. It does not typically indicate a pathological condition unless accompanied by central cyanosis.

Mucus draining from the nose: Mild nasal secretions are common in newborns due to residual amniotic fluid or normal respiratory clearing. This is a normal finding and does not require urgent reporting.

Irregular heart rate: Newborns often have transient variations in heart rate shortly after birth, especially during sleep or activity. Mild irregularities are usually benign and expected during the adaptation period.

Enlarged fontanelle: An enlarged fontanelle refers to an abnormally large soft spot on the newborn’s skull, which may indicate increased intracranial pressure or delayed bone closure. It does not describe a localized scalp swelling limited by suture lines.

Caput succedaneum: Caput succedaneum is generalized edema of the scalp that crosses suture lines. It is often present at birth due to pressure during delivery and resolves within a few days.

Molding: Molding refers to the shaping of the newborn’s skull during passage through the birth canal, resulting in overlapping of the cranial bones. It is temporary and affects the shape of the head rather than presenting as a localized swelling.

Delivery of the post-term infant is more difficult: While post-term infants may present challenges during delivery, this does not explain why the newborn requires close monitoring after birth. The focus is on postnatal adaptation rather than delivery difficulty.

Infants born post-maturely are generally large: Some post-term infants are macrosomic, but not all, and size alone does not determine the need for intensive observation. Monitoring is based on physiologic risks rather than solely on weight.

There is less amniotic fluid: Oligohydramnios can occur with post-term pregnancies, but the primary concern for close neonatal observation is related to placental insufficiency rather than amniotic fluid volume alone.

Settling down: This stage refers to the gradual adjustment to parenthood over time, often weeks after birth. It involves adapting to the new family role and establishing routines, rather than the immediate confidence in performing newborn care.

Letting go: The letting go stage occurs later when the parent accepts the new role fully and relinquishes previous expectations or idealized views of parenthood. It is not typically observed in the first few days postpartum.

Taking in: The taking in stage occurs immediately after birth and focuses on the mother’s need for rest, reflection on the birth experience, and reliance on others for care. It involves more passive observation rather than active participation in newborn care.

Initiate oxygen therapy by nonrebreather mask: While oxygen may be indicated for hypovolemia or shock, immediate assessment of the cause of hypotension takes priority. Oxygen alone does not address the underlying source of potential postpartum hemorrhage.

Administer oxytocin infusion: Oxytocin helps contract the uterus and reduce bleeding, but it should be administered after assessing the uterus to confirm atony. Administering medications without assessment could delay targeted intervention.

Obtain a type and crossmatch: Preparing for possible transfusion is important in hemorrhage management, but it is not the first action. Immediate assessment and control of bleeding take precedence to stabilize the client.

Serosa: Lochia serosa appears several days after delivery, typically around day 4 to 10, and is pinkish or brownish in color. It is not the initial type of lochia observed immediately postpartum.

Vaginalis: Vaginalis is not a recognized classification of lochia. The standard types include rubra, serosa, and alba.

Alba: Lochia alba occurs later, around 10–14 days postpartum, and can persist for several weeks. It is whitish or yellowish and contains mostly leukocytes and epithelial cells rather than blood.

Fundus palpable at the umbilicus: A firm fundus at the level of the umbilicus is an expected finding at 12 hours postpartum and indicates effective uterine contraction. It does not suggest a complication.

Urine output of 3,000 mL in 12 hr: Increased urine output in the first 12–24 hours postpartum is common as the body eliminates excess fluid accumulated during pregnancy. This is a normal physiologic response and not a complication.

Heart rate 110/min: Mild tachycardia can occur postpartum due to pain, anxiety, or mild physiologic changes. While it should be monitored, it is less immediately concerning than orthostatic hypotension, which poses greater risk to maternal stability.