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Slight abdominal cramps are a common symptom of early pregnancy and do not necessarily mean that a miscarriage is happening. However, if the cramps are severe, persistent, or accompanied by bleeding, then they could be a sign of a problem and should be reported to the provider.

hCG (human chorionic gonadotropin) is a hormone produced by the placenta during pregnancy. It can be measured in the blood or urine to confirm pregnancy or monitor its progress. Elevated hCG levels are not a sign of a spontaneous abortion, but rather a normal finding in early pregnancy. In fact, low or decreasing hCG levels may indicate a miscarriage or an ectopic pregnancy.

Scant bright red spotting is another common symptom of early pregnancy and does not necessarily mean that a miscarriage is happening. It may be caused by implantation bleeding, cervical irritation, or sexual intercourse. However, if the spotting is heavy, dark, or accompanied by cramps or pain, then it could be a sign of a problem and should be reported to the provider.

A: This is a normal urinary output for an adult. A normal urinary output is 0.5 to 1 mL/kg/hr³. Assuming an average weight of 70 kg, this would be 35 to 70 mL/hr, or 70 to 140 mL in 2 hr. Therefore, a urinary output of 120 mL in 2 hr is within the normal range and does not need to be reported.

C: This is a reassuring sign of fetal well-being. Fetal heart rate variability is the amount of fluctuation in the fetal heart rate from the baseline. Moderate variability is defined as a fluctuation of 6 to 25 beats per minute (bpm) and indicates that the fetus is responsive and has adequate oxygenation⁴. Moderate variability does not need to be reported.

D: This is a slightly elevated blood pressure, but not a sign of an adverse effect from butorphanol. Butorphanol does not cause significant changes in blood pressure¹. A normal blood pressure for an adult is less than 120/80 mm Hg⁵. A blood pressure of 136/88 mm Hg is considered elevated, but not hypertensive. The nurse should monitor the client's blood pressure and check for other signs of preeclampsia, such as proteinuria, headache, or visual changes. However, this finding does not need to be reported immediately.

A: This does not elicit the Moro reflex, but rather the tonic neck reflex. The tonic neck reflex occurs when the infant turns their head to one side and assumes a "fencing" posture, with the arm and leg on the same side extended and the opposite arm and leg flexed.

B: This does not elicit the Moro reflex, but rather the rooting reflex. The rooting reflex occurs when the infant turns their head and opens their mouth in response to a touch on their cheek or mouth. This reflex helps the infant locate and latch onto a nipple for feeding³.

D: This does not elicit the Moro reflex, but rather the glabellar reflex. The glabellar reflex occurs when the infant blinks in response to a tap on their forehead or bridge of their nose. This reflex helps protect the eyes from injury³.

A: Raw carrots are a healthy vegetable that provide vitamin A, fiber, and antioxidants. However, they are not a good source of riboflavin. One medium carrot contains only 0.02 milligrams of riboflavin, which is less than 2% of the recommended daily amount⁴.

B: Fresh citrus fruits are a great source of vitamin C, folate, and potassium. However, they are not a good source of riboflavin. One medium orange contains only 0.04 milligrams of riboflavin, which is about 4% of the recommended daily amount⁴.

C: Brown rice is a whole grain that provides complex carbohydrates, fiber, and minerals. However, it is not a good source of riboflavin. One cup of cooked brown rice contains only 0.05 milligrams of riboflavin, which is about 5% of the recommended daily amount⁴.

A: Single palmar creases are single lines that cross the palm of the hand, formed by the fusion of two normal creases¹. They are present in about 1 out of 30 people, more often in males than females¹. They are usually harmless and do not affect the function of the hand¹. However, they may be associated with some genetic or developmental disorders, such as Down syndrome, fetal alcohol syndrome, or Aarskog syndrome¹³.Therefore, the nurse should examine the baby for any other physical anomalies or signs of chromosomal abnormalities and refer them to a geneticist if needed.

C: Subconjunctival hemorrhage is a burst blood vessel in the white of the eye, causing a bright red spot on the eye[^10^]. It is usually painless and does not affect vision[^10^]. It is very common in newborns after a traumatic delivery, especially when forceps or vacuum extraction are used[^10^] ¹²¹⁴. It is usually benign and resolves on its own within 1-2 weeks[^10^]. The nurse should reassure the parents and monitor the baby for any signs of infection or bleeding disorders.

D: Transient circumoral cyanosis is a blue discoloration around the mouth only, caused by low levels of oxygen in the blood vessels near the skin surface¹⁵. It is often seen in infants during the first few days after birth or when they are exposed to cold temperatures¹⁵. It is usually normal and harmless and goes away once they warm up¹⁵. However, if the cyanosis affects other parts of the face or body, such as the lips or tongue, it could be a sign of a serious lung or heart problem and should be reported immediately¹⁵. The nurse should check the baby's oxygen saturation, heart rate, and respiratory rate and look for any signs of distress.

A: This is not an appropriate action for early decelerations, as they are not caused by maternal position or uteroplacental insufficiency. Changing the maternal position may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.

C: This is not an appropriate action for early decelerations, as they are not caused by oxytocin administration or uterine hyperstimulation. Oxytocin is a hormone that stimulates uterine contractions and can be used to induce or augment labor. However, excessive or prolonged use of oxytocin can cause uterine fatigue and reduce its ability to contract after delivery, leading to uterine atony and postpartum hemorrhage². Oxytocin can also cause late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.

D: This is not an appropriate action for early decelerations, as they are not caused by fetal hypoxia or acidosis. Oxygen administration may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.

Taking more insulin with each meal than you did prior to pregnancy may cause hypoglycemia, especially if you are breastfeeding. You should adjust your insulin doses according to your blood glucose levels and carbohydrate intake, and consult your doctor or diabetes educator for guidance²³.

Checking your blood glucose levels every 8 hours is not frequent enough to monitor your diabetes during breastfeeding. You should check your blood glucose levels before and after each breastfeeding session, as well as before meals and snacks, at bedtime, and during the night if needed²³.

Limiting your carbohydrate intake to 30 grams per day is too restrictive and may impair your milk production and quality, as well as cause hypoglycemia or ketoacidosis. You should consume adequate carbohydrates from healthy sources, such as whole grains, fruits, vegetables, legumes, and dairy products, to meet your energy and nutritional needs²³.

Applying oxygen via nonrebreather face mask at 2 L/min is not an effective intervention for maternal hypotension. Oxygen supplementation may be beneficial for improving fetal oxygenation in case of fetal distress, but it does not directly increase maternal blood pressure or cardiac output¹². Moreover, 2 L/min is a low flow rate for a nonrebreather face mask, which requires at least 10 L/min to deliver high concentrations of oxygen⁴.

Positioning the client in a knee-chest position is not a recommended intervention for maternal hypotension. This position may increase venous return and cardiac output in some cases, but it also increases intra-abdominal pressure and reduces uterine blood flow, which can compromise fetal oxygenation and well-being. A left lateral tilt position of 15 to 30 degrees is preferred to avoid aortocaval compression and improve placental perfusion¹².

Giving terbutaline subcutaneously is not an appropriate intervention for maternal hypotension. Terbutaline is a beta-agonist that relaxes the uterine smooth muscle and prevents preterm labor contractions. It has no direct effect on maternal blood pressure or cardiac output, and it may cause maternal tachycardia, palpitations, tremors, and hypokalemia as side effects. Vasopressors such as ephedrine or phenylephrine are more effective and safer drugs for treating maternal hypotension¹².