A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

Choice A Reason:

Reassess the client in 2 hours is inappropriate. While reassessment is important, addressing the cause of uterine displacement, in this case, a full bladder, should be the initial priority.

Choice B Reason:

Administering simethicone is inappropriate. Simethicone is typically used to relieve gas and bloating. It is not the primary intervention for uterine displacement related to bladder fullness.

Choice C Reason:

Assisting the client to empty her bladder is appropriate. A full bladder can displace the uterus and hinder its contraction, leading to potential issues such as uterine atony or increased postpartum bleeding. Emptying the bladder helps the uterus contract more effectively.

Choice D Reason:

Instructing the client to lie on her right side is inappropriate. Lying on the right side is often recommended to improve blood flow and oxygenation to the fetus during pregnancy but may not directly address uterine displacement caused by a full bladder. The priority is to assist the client in emptying her bladder.

The correct answer is A.

A. Oligohydramnios: Oligohydramnios is a condition characterized by a lower-than-normal level of amniotic fluid in the uterus. Fetal assessment using electronic fetal monitoring may be indicated to monitor the well-being of the fetus, as oligohydramnios can be associated with fetal growth restriction and other complications.

B. Hyperemesis gravidarum: Hyperemesis gravidarum refers to severe nausea and vomiting during pregnancy. While it can be a challenging condition, it is not typically an indication for electronic fetal monitoring. Fetal monitoring is generally performed for conditions that directly impact the well-being of the fetus.

C. Leukorrhea: Leukorrhea refers to an increase in vaginal discharge, which is a common and normal occurrence during pregnancy. It is not an indication for electronic fetal monitoring, as it does not directly impact fetal well-being.

D. Periodic tingling of the fingers: Periodic tingling of the fingers is not typically an indication for fetal assessment using electronic fetal monitoring. It may be related to factors such as nerve compression or changes in circulation but is not a direct indication for monitoring the fetus.