A nurse is caring for a client who wants to know if it is possible to have a vaginal birth after a cesarean birth (VBAC). Which of the following statements by the nurse is appropriate?

Choice A reason:

Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure is usually normal or slightly elevated in NAS, and it is not a reliable indicator of the severity of withdrawal symptoms.

Choice B reason:

Gastrointestinal disturbances are a common and serious finding for a newborn with NAS. Vomiting and diarrhea can lead to dehydration, electrolyte imbalance, and poor weight gain. Projectile vomiting can also increase the risk of aspiration. This finding requires immediate follow-up and intervention.

Choice C reason:

Skin color is not a priority finding for a newborn with NAS. Acrocyanosis (bluish color of the hands and feet) is a normal finding in newborns and does not indicate hypoxia or poor circulation. It usually resolves within the first few days of life.

Choice D reason:

NAS score is not a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. It is based on a set of clinical signs and symptoms that are scored at regular intervals. However, it is not a substitute for clinical judgment and individualized care. The NAS score alone does not determine the urgency of follow-up.

Choice E reason:

Temperature is not a priority finding for a newborn with NAS. The temperature may be slightly elevated or normal in NAS, and it is not a specific sign of infection or withdrawal. Temperature regulation is important for newborns, but it is not an immediate concern in this case.

Choice F reason:

Oxygen saturation is a priority finding for a newborn with NAS. Tachypnea (rapid breathing) and retractions (inward movement of the chest wall) are signs of respiratory distress, which can compromise oxygen delivery to the tissues and organs. Hypoxia (low oxygen level) can cause brain damage, organ failure, and death if not corrected promptly. This finding requires immediate follow-up and intervention.

Choice G reason:

Central nervous system disturbances are a priority finding for a newborn with NAS. Increased muscle tone, tremors, high-pitched cries, and seizures are signs of neurological dysfunction, which can indicate brain injury, bleeding, or infection. Seizures can also worsen hypoxia and metabolic acidosis. This finding requires immediate follow-up and intervention.

Choice H reason:

Respiratory rate is not a priority finding for a newborn with NAS. Respiratory rate may be increased or normal in NAS, and it is not a specific sign of respiratory distress or infection. Respiratory rate should be monitored along with other vital signs, but.

Choice A reason:

Attachment phase is not one of Rubin's phases of role attachment. Rubin's theory of maternal role adaptation describes three stages that the mother goes through during the postpartum period: taking in, taking hold and letting go.

Choice B reason:

Letting go phase is the last stage of Rubin's theory of role attachment. It occurs when the mother accepts her new role and gives up her old roles. She also comes to terms with the reality of the birthing experience and the characteristics of her baby.

Choice C reason:

Taking hold phase is the second stage of Rubin's theory of role attachment. It occurs when the mother becomes interested in caring for the infant and learning about her baby and herself. She may be critical about her care-giving abilities and need positive reinforcement.

Choice D reason:

Taking in phase is the first stage of Rubin's theory of role attachment. It occurs right after the birth of the child, when the mother is passive and focused on her own needs, especially sleeping and eating. She may have limited interactions with her infant and prefer to talk about her experiences during labor, birth, and pregnancy. This matches the description of the new mother in the question, so this is the correct answer.