A nurse is caring for a term newborn who is 48 hr old

Exhibits

The nurse assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

A. Painful intercourse: Painful intercourse can have various causes, but it is not typically associated with serious complications related to oral contraceptives. It may be addressed with the healthcare provider during a routine follow-up.

B. Vaginal itching: Vaginal itching may be due to various reasons, including infections, but it is not typically a direct side effect of oral contraceptives. However, if the itching is persistent or severe, the client should report it to the provider for appropriate evaluation.

C. Persistent headaches: Persistent headaches can be a concerning side effect associated with the use of oral contraceptives. It may indicate an increased risk of vascular events, such as stroke or thrombosis. Clients experiencing persistent headaches while on oral contraceptives should report this symptom to the healthcare provider immediately for further evaluation.

D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives, and it is not typically an emergency or a sign of serious complications. However, if the breast tenderness is severe or associated with other concerning symptoms, the client should contact the provider for guidance.

A. Three fetal movements perceived by the client in a 20-min testing period: Perceiving fetal movements during the testing period is a positive finding and indicative of fetal well-being.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period: This is considered a reassuring result in an NST, showing an appropriate acceleration in the fetal heart rate in response to fetal movement, which is a normal and positive finding.

C. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client

During a nonstress test (NST), the presence of uterine contractions can sometimes interfere with the interpretation of fetal heart rate (FHR) patterns. If contractions occur but are not felt by the client, it can affect the accuracy of the test. Therefore, irregular contractions that are not felt by the client may prompt the need for further evaluation or testing to ensure accurate assessment of fetal well-being.

D. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period: Absence of late decelerations during uterine contractions is also a reassuring finding, indicating that the baby is tolerating the stress of contractions well.