A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?

Choice A rationale:

This statement is incorrect. A nonstress test does not involve receiving medication through an

IV. It is a simple and non-invasive test that monitors the baby's heart rate in response to its movements.

Choice B rationale:

This is the correct choice. A nonstress test typically takes about 30 minutes to complete. During the test, the client will have a fetal heart rate monitor placed on her abdomen to measure the baby's heart rate while it is moving.

Choice C rationale:

This statement is incorrect. There is no requirement for the client to fast or restrict food and drink before a nonstress test. The client can eat and drink as usual before the procedure.

Choice D rationale:

This statement is incorrect. A nonstress test is not used to determine if the baby's lungs are mature. Instead, it assesses the baby's heart rate patterns in response to its own movements, which helps evaluate the baby's overall well-being in the third trimester of pregnancy.

Choice C rationale:

The nurse should first massage the client's fundus to address the excessive vaginal bleeding. Massaging the fundus helps the uterus contract and prevents further bleeding. Excessive postpartum bleeding may indicate uterine atony, which is a leading cause of postpartum hemorrhage. The nurse should apply gentle pressure to the fundus to promote uterine contractions and reduce bleeding.

Choice A rationale:

Elevating the client's legs to a 30° angle (Trendelenburg position) is not the priority action in this situation. Fundal massage takes precedence because it directly addresses the cause of the excessive bleeding. While Trendelenburg position might be used in some situations to increase blood flow to vital organs, it is not the first-line intervention for postpartum bleeding.

Choice B rationale:

Inserting an indwelling urinary catheter is not the priority action for excessive vaginal bleeding. While monitoring urine output is essential, the immediate concern is controlling the bleeding by massaging the fundus.

Choice D rationale:

Initiating an infusion of oxytocin may be indicated if fundal massage alone is insufficient to control bleeding. However, massaging the fundus should be the first action taken to promote uterine contractions. Oxytocin can be administered afterward, if needed, under the direction of a healthcare provider.