A nurse is collecting data from a newborn immediately after delivery by a client who was at 42 weeks of gestation. Which of the following findings should the nurse expect?

Choice A reason:

FAS is caused by alcohol, and NAS is caused by opioids. This is the correct answer because FAS stands for fetal alcohol syndrome, which is a group of physical and mental defects that can occur in a baby when a woman drinks alcohol during pregnancy. NAS stands for neonatal abstinence syndrome, which is a group of problems that can happen when a baby is exposed to opioid drugs for a length of time while in their mother's womb.

Choice B reason:

FAS and NAS are both incurable. This is incorrect because FAS and NAS have different outcomes. FAS is incurable because the effects of alcohol on the developing brain and body are permanent. NAS, however, can be treated with medication and supportive care to help the baby cope with withdrawal symptoms and prevent complications.

Choice C reason:

FAS and NAS are both curable. This is incorrect because FAS is not curable, as explained above. NAS can be treated, but not cured, because some babies may have long-term problems such as developmental delays, behavioral issues, or learning difficulties.

Choice D reason:

FAS is caused by analgesics and NAS is caused by NSAIDs. This is incorrect because FAS is caused by alcohol, not analgesics, which are painkillers. NAS is caused by opioids, not NSAIDs, which are anti-inflammatory drugs. Analgesics and NSAIDs do not cause the same type of damage to the fetus or the newborn as alcohol and opioids do.

Choice A:

Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.

Choice B:

Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.

Choice C:

Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.

Choice D:

Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.

Choice E:

Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.