A nurse is caring for a patient who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR.
After discontinuing the infusion, what action should the nurse take?

Choice A rationale
The use of an oil-based vaginal lubricant when inserting a diaphragm is not recommended. Oil- based lubricants can damage the material of the diaphragm, reducing its effectiveness as a contraceptive method.
Choice B rationale
Keeping the diaphragm in place for at least 4 hours after intercourse is a standard recommendation. However, it does not address the specific needs of a postpartum woman. After childbirth, the size and shape of a woman’s vagina can change, potentially affecting the fit of the diaphragm.
Choice C rationale

The provider should refit the client for a new diaphragm. After childbirth, the size and shape of a woman’s vagina can change, potentially affecting the fit of the diaphragm. A poorly fitting diaphragm may not provide effective contraception.
Choice D rationale
Storing the diaphragm in sterile water after each use is not a standard recommendation. The diaphragm should be cleaned with mild soap and water, dried, and stored in a cool, dry place.

Choice A rationale
Rust-stained urine is not a normal finding in a full-term newborn and should be reported to the provider. However, it is not typically assessed upon admission to the nursery.
Choice B rationale
Subconjunctival hemorrhage, or a small red or pink spot on the white of the eye, can occur due to the pressure changes during the birth process. It is a harmless condition that does not affect the baby’s vision and does not require treatment.
Choice C rationale
Single palmar creases, also known as “simian lines,” can be a normal variation in hand creases. However, they are also associated with certain genetic conditions, such as Down syndrome, and should be reported to the provider.
Choice D rationale
Transient circumoral cyanosis, or bluish color around the mouth, can be a normal finding in newborns when they are cold or after crying. However, if it persists, it could indicate a problem with the baby’s heart or lungs and should be reported to the provider.