A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?

A. Weak cry

While infants with neonatal abstinence syndrome (NAS) may exhibit irritability and excessive crying, a weak cry specifically is not typically associated with NAS. A weak cry could indicate other issues such as respiratory distress or neurological problems, but it is not a characteristic manifestation of NAS.

B. Absent Moro reflex

The Moro reflex is a normal primitive reflex present in newborns, involving the sudden extension and then flexion of the infant's arms in response to a sensation of falling or a loud noise. While NAS can affect the nervous system, leading to irritability and tremors, it typically does not cause the complete absence of the Moro reflex. Thus, this choice is less likely.

C. Respiratory rate of 30/min

A respiratory rate of 30/min in a newborn is within the normal range. While NAS can sometimes cause respiratory distress, it would typically present as symptoms such as rapid breathing, not necessarily a specific rate like 30/min. Therefore, this choice is not strongly associated with NAS.

D. Poor feeding

Poor feeding is a common manifestation of neonatal abstinence syndrome (NAS). Infants born to mothers who used methadone during pregnancy often experience withdrawal symptoms, including irritability and gastrointestinal issues, which can interfere with their ability to feed effectively. Poor feeding is a hallmark sign of NAS and is frequently observed in affected newborns.

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.

Irregular contractions alone are not necessarily concerning. However, if they are not felt by the client, it may indicate decreased fetal movement. Further evaluation is needed to ensure the baby’s well-being.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.

An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period:This finding is reassuring.A reactive NST (with accelerations in FHR) indicates that the baby is healthy and responsive to moveme.

C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.

The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.

D. Three fetal movements perceived by the client in a 20-min testing period.

Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.
Irregular contractions of short duration that are not perceived by the client are not typically concerning during a nonstress test (NST). The primary focus of an NST is to assess fetal heart rate patterns in response to fetal movement and uterine activity. As long as these contractions do not lead to decelerations or other signs of fetal distress, they are not usually indicative of a problem.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.
This is the correct answer. While fetal heart rate accelerations in response to fetal movement are typically reassuring during an NST, an acceleration of 150 beats per minute above the baseline heart rate, lasting 10 seconds, could indicate fetal distress or compromise. Such a significant increase may suggest that the fetus is having difficulty compensating for stress or may be experiencing hypoxia, necessitating further evaluation.

C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.

D. Three fetal movements perceived by the client in a 20-min testing period.
Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.