A nurse is assessing a client who received methylergonovine to treat uterine atony in the fourth stage of labor.
Which of the following findings should the nurse identify as an adverse effect of the medication?

Choice A rationale

Initiating internal fetal heart rate monitoring is an invasive procedure that is not the priority for a non-reassuring fetal heart rate pattern like late decelerations, which often indicate uteroplacental insufficiency. The first step involves non-invasive intrauterine resuscitation measures to immediately improve fetal oxygenation before considering invasive monitoring, unless the external tracing is inadequate.

Choice B rationale

Late decelerations are an indication of uteroplacental insufficiency (decreased blood flow/oxygen to the fetus during the contraction). Assisting the client to a left lateral position is the priority nursing action because it relieves pressure from the gravid uterus on the vena cava, which in turn maximizes venous return to the heart and increases blood flow and oxygen delivery to the placenta and fetus.

Choice C rationale

While uterine tachysystole (excessive frequency of contractions, greater than five in 10 minutes over 30 minutes) can cause late decelerations, palpating for it is not the absolute first action. The immediate priority is to improve fetal oxygenation by repositioning the mother. Palpation for tachysystole, however, is a quick assessment that should follow the repositioning intervention.

Choice D rationale

Increasing the infusion rate of the maintenance IV fluid (an IV fluid bolus) is a critical step in intrauterine resuscitation for late decelerations. It increases maternal blood volume, which can improve placental perfusion. However, repositioning the client is generally the most immediate, least invasive, and first step to correct or improve the blood flow to the placenta and fetus.

Choice A rationale

Soft grunting noises during expiration are a sign of mild to moderate respiratory distress in a newborn. Grunting is the newborn's attempt to keep the alveoli open by increasing Positive End-Expiratory Pressure (PEEP), suggesting decreased lung compliance or insufficient surfactant. This finding requires immediate notification of the provider for evaluation and potential intervention.

Choice B rationale

A positive Babinski reflex, which involves the great toe dorsiflexing and the other toes fanning out upon stroking the sole of the foot, is a normal neurological finding in a newborn and infant. This reflex persists until about 1 to 2 years of age as the central nervous system matures, and therefore does not require reporting.

Choice C rationale

Acrocyanosis, which is pale blue hands and feet with pinkish trunk and mucous membranes, is a common and normal finding in a newborn during the first 24 to 48 hours after birth due to immature peripheral circulation and cold exposure. This peripheral vasoconstriction resolves spontaneously and is not typically reported unless accompanied by central cyanosis.

Choice D rationale

Blood-tinged discharge from the vagina, often called pseudomenstruation, is a normal, transient finding in female newborns. It is caused by the withdrawal of maternal estrogen hormones following birth, leading to a minor sloughing of the uterine endometrium, and does not indicate a pathological condition requiring immediate reporting.