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?

Water retention

Tachycardia

Seizures

Hypertension

Answer and Explanation

The Correct Answer is D

A. Water retention is not a common adverse effect of methylergonovine.
B. Tachycardia is not typically caused by methylergonovine; bradycardia or hypertension is more common.
C. Seizures are not a common side effect of this medication.
D. Hypertension is a known adverse effect of methylergonovine and requires close monitoring, especially in clients with preexisting hypertension.

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Correct Answer is C

Explanation

A. Subconjunctival hemorrhage is common after vaginal delivery and usually harmless.
B. Overlapping suture lines are normal in newborns due to molding during birth.
C. Nasal flaring is a sign of respiratory distress and requires immediate assessment.
D. Rust-stained urine can be due to urate crystals and is usually benign in newborns.

A. Instruct the parent to avoid eye contact with the newborn during feeding. B. Weigh the newborn daily. C. Plan to administer naloxone. D. Instruct the parent to avoid breastfeeding E. Maintain a low stimulation environment F. Swaddle the newborn with flexed extremities. G. Perform Ballard newborn screening each shift.

Correct Answer is ["B","E","F"]

Explanation

A. Instruct the parent to avoid eye contact with the newborn during feeding – This is not recommended. While overstimulation should be minimized, gentle eye contact and bonding are still encouraged during feeding to promote attachment.

B. Weigh the newborn daily – Weight loss and feeding difficulties are common in NAS. Daily weight monitoring is essential to evaluate nutritional status and fluid balance.

C. Plan to administer naloxone – Naloxone is contraindicated in opioid-exposed neonates because it can precipitate acute withdrawal and seizures.

D. Instruct the parent to avoid breastfeeding – Breastfeeding is generally encouraged unless the mother is using illicit substances or is HIV-positive. Methadone is not a contraindication for breastfeeding.

E. Maintain a low stimulation environment – NAS newborns are easily overstimulated. A quiet, dimly lit environment helps reduce symptoms like irritability and tremors.

F. Swaddle the newborn with flexed extremities – Swaddling provides comfort and containment, helping to reduce stress responses in NAS infants.

G. Perform Ballard newborn screening each shift – The Ballard score is used once to assess gestational age and is not repeated every shift.

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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?

Nursing Test Bank

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