A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?

The correct answer is choiceA. Continue to monitor the client.

Choice A rationale:

Early decelerations are typically benign and are caused by fetal head compression during contractions.They usually do not require any specific intervention other than continued monitoring to ensure they remain early decelerations and do not progress to more concerning patterns.

Choice B rationale:

Discontinuing oxytocin is not necessary for early decelerations, as they are not indicative of fetal distress.Oxytocin would be discontinued if there were signs of more severe decelerations or other complications.

Choice C rationale:

Assisting the client to lay on her right side is not specifically required for early decelerations.This position change is more commonly used for variable or late decelerations to improve uteroplacental blood flow.

Choice D rationale:

Administering oxygen at 8 L/min per mask is not needed for early decelerations.Oxygen is typically reserved for situations where there is evidence of fetal hypoxia or distress.

Choice A rationale:

The nurse should not measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr because this action does not address the specific problem presented in the scenario, which is abdominal distention and bloody stools. Measuring abdominal circumference is typically done to assess for growth and may not provide valuable information in this situation.

Choice B rationale:

Inserting an orogastric decompression tube with low wall suction is the appropriate action for a newborn with abdominal distension and bloody stools. This intervention can help decompress the gastrointestinal tract, reducing abdominal distention, and possibly preventing further complications.

Choice C rationale:

Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated based on the information provided in the scenario. The newborn's symptoms are suggestive of gastrointestinal issues, and this intervention may not address the underlying cause.

Choice D rationale:

Administering nitric oxide inhalation therapy to the newborn is not appropriate in this context. Nitric oxide inhalation therapy is typically used for conditions like persistent pulmonary hypertension in the newborn, and there is no indication for its use in this case.