A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Excessive high-pitched cry as an indication of neonatal abstinence syndrome (NAS) in a newborn with a maternal history of methadone use during pregnancy. Neonatal abstinence syndrome occurs when a newborn experiences withdrawal symptoms from substances the mother used during pregnancy, such as opioids like methadone. The high-pitched cry is a common manifestation of NAS, indicating central nervous system irritability. This cry is often shrill, continuous, and may sound distressed. Other signs of NAS include irritability, tremors, poor feeding, vomiting, diarrhea, sweating, fever, and respiratory issues. Option A) Hyporeactivity is incorrect because NAS typically presents with hyperactivity and not hypoactivity. Option C) Acrocyanosis is a common finding in newborns and does not specifically indicate NAS. Option D) Respiratory rate of 50/min is within the normal range for a newborn and is not a specific sign of NAS. Educationally, understanding the manifestations of NAS is crucial for healthcare professionals working with newborns exposed to substances in utero. Early recognition and appropriate management of NAS are vital to ensure the well-being of these vulnerable infants. Healthcare providers should be knowledgeable about the signs and symptoms of NAS to provide timely and effective interventions for affected newborns.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to change the client's position (Option A). Late decelerations in the fetal heart rate (FHR) indicate uteroplacental insufficiency, which could be caused by pressure on the mother's vena cava due to supine position. Changing the client's position can help relieve this pressure, improving blood flow to the placenta and potentially resolving the late decelerations. Option B, palpating the uterus to assess for tachysystole, is not the first action to take in this situation because addressing the fetal heart rate pattern is the priority. Option C, increasing the client's IV infusion rate, and Option D, administering oxygen, are important interventions but are not the initial steps when late decelerations are detected. From an educational perspective, it is crucial for nurses to prioritize interventions based on the urgency of the situation. Understanding the pathophysiology behind late decelerations and knowing the appropriate interventions can help nurses provide effective and timely care to clients in labor, ultimately improving maternal and fetal outcomes.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Hypotension, which indicates the client is experiencing decreased cardiac output. When a client is experiencing excessive vaginal bleeding after childbirth, it can lead to hypovolemia, resulting in decreased blood volume and subsequently decreased cardiac output. Hypotension is a key indicator of reduced perfusion to vital organs due to the heart's inability to pump effectively. Option A) Bradycardia is incorrect because a slow heart rate may be a compensatory mechanism in response to decreased cardiac output, but it is not a direct indicator of decreased cardiac output in this context. Option B) Flushed face is incorrect as it is more likely related to increased peripheral vasodilation rather than decreased cardiac output. Option D) Polyuria is incorrect because it is excessive urination and not directly related to cardiac output. Educationally, understanding the signs and symptoms of decreased cardiac output in postpartum clients is crucial for nurses to provide timely and appropriate interventions to prevent complications such as hypovolemic shock. Monitoring vital signs like blood pressure is essential in assessing maternal health status post-delivery and ensuring early recognition of potential complications.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Head compression, which causes early decelerations in the fetal heart rate (FHR). During labor, as the fetus descends through the birth canal, pressure on the fetal head can lead to a vagal response, resulting in early decelerations. This is a normal response to head compression and is not typically associated with fetal distress. Option A) Fetal hypoxemia is characterized by late decelerations in the FHR, not early decelerations. This indicates oxygen deprivation in the fetus. Option B) Cord compression can lead to variable decelerations in the FHR, not early decelerations. Variable decelerations are usually caused by umbilical cord compression during contractions. Option C) Uteroplacental insufficiency is associated with late decelerations in the FHR, not early decelerations. This condition reflects inadequate blood flow and oxygen transfer across the placenta. Understanding the causes of different types of decelerations in the FHR is crucial for nurses and healthcare providers caring for laboring women. Recognizing the significance of early decelerations due to head compression helps differentiate normal physiological responses from potentially concerning fetal distress, leading to appropriate interventions and improved maternal and fetal outcomes.

Correct Answer: D

Rationale: In this scenario, the nurse should see client D first, who gave birth 8 hours ago and is saturating a perineal pad every hour. This client is exhibiting signs of excessive postpartum bleeding, which could indicate postpartum hemorrhage, a life-threatening complication. Prompt assessment and intervention are crucial in this situation to prevent further complications or even death. Option A can be ruled out because while Rho(D) immune globulin is important for Rh-negative mothers, it is not an urgent issue compared to postpartum hemorrhage. Option B, breast fullness, is a common postpartum issue related to breast engorgement and can be addressed after ensuring client D's stability. Option C's increase in urinary output, while needing monitoring for possible diuresis, does not pose an immediate threat to the client's life. This educational context highlights the importance of prioritizing care in postpartum settings, focusing on critical thinking and swift decision-making to ensure the safety and well-being of postpartum clients. Nurses must be able to recognize and respond to signs of complications promptly to provide optimal care in maternal health settings.