A nurse is caring for a newborn in the newborn nursery unit.

Exhibits

After reviewing the information in the newborn's electronic medical record (EMR), which of the following findings should the nurse report to the provider? Click to highlight below the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

 

Body system	Findings
Neurologic	Irritability
	Pupil response
Integumentary	Milia on nose and cheeks
	Lanugo on bilateral shoulders
Cardiopulmonary	Axillary temperature
	Respiratory rate
	Apical heart rate
	Lung findings
Gastrointestinal	Stool characteristics
	Abdomen findings

Choice A rationale

Nausea is a very common, generally mild, and often transient side effect of oral contraceptives, usually caused by the estrogen component. It typically improves over a few cycles as the body adjusts to the hormonal changes and does not usually necessitate immediate notification of the healthcare provider.

Choice B rationale

Abdominal bloating is a frequent and minor adverse effect of hormonal contraception, often related to fluid retention or altered gastrointestinal motility due to hormonal fluctuation, which is usually self-limiting or manageable with minor adjustments, thus not requiring urgent reporting.

Choice C rationale

Breast tenderness or mastalgia is a common, dose-related side effect linked to hormonal stimulation (estrogen and/or progestin) of the mammary tissue, similar to premenstrual symptoms, and is generally considered a nuisance rather than an immediate danger sign.

Choice D rationale

Persistent headaches, especially if severe, unilateral, or associated with visual changes, can be a symptom of a serious adverse event like a cerebrovascular accident (stroke) or thrombotic events (e.g., cerebral venous thrombosis), which are rare but serious risks associated with hormonal contraceptives, necessitating immediate medical evaluation.

Explanations

Fetal presentation The fetus is in a left occiput anterior (LOA) vertex presentation, which is the most favorable position for vaginal birth. LOA allows for optimal alignment of the fetal head with the maternal pelvis, facilitating descent and rotation during labor. Malpresentations such as breech or transverse would be unfavorable, but vertex LOA is considered ideal. Therefore, this finding is favorable for vaginal delivery at 42 weeks gestation.

Cervical findings The cervix is described as closed and thick, which is unfavorable for vaginal birth. At 42 weeks, the cervix should ideally be effaced and dilated to allow for labor progression. A closed, thick cervix indicates that the cervix has not ripened, which may necessitate induction with cervical ripening agents such as prostaglandins or mechanical methods. Thus, this finding is not favorable for vaginal birth readiness.

Uterine contraction pattern The client reports only occasional mild uterine contractions, which is not favorable for vaginal birth at 42 weeks. Effective labor requires regular, strong contractions that cause progressive cervical dilation and effacement. Occasional mild contractions are insufficient to initiate or sustain active labor. At this post-term stage, the absence of an adequate contraction pattern suggests that induction may be required. Therefore, this finding is not favorable.

FHR The fetal heart rate is 150/min, which falls within the normal baseline range of 110 to 160 beats per minute. This indicates adequate fetal oxygenation and no evidence of tachycardia or bradycardia. A normal FHR is a favorable finding for vaginal birth, as it reflects reassuring fetal status. Continuous monitoring remains important, but this specific finding supports safe progression toward vaginal delivery.