A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake.
The nurse should instruct the client that which of the following foods has the highest amount of calcium?

Rationales

A. Rust-stained urine.
Rust or brick-dust staining in the diaper is usually caused by urate crystals in the urine. This is a common and benign finding in newborns during the first days of life, particularly when fluid intake is still low. It does not require provider notification unless it persists beyond the first week or is accompanied by other abnormalities.

B. Subconjunctival hemorrhage.
A subconjunctival hemorrhage often results from pressure during delivery, especially in vaginal births. It appears as a bright red patch on the sclera but is harmless and resolves spontaneously within several weeks. It is considered a normal newborn finding and does not need to be reported.

C. Single palmar creases.
A single transverse palmar crease, also known as a simian crease, can be associated with chromosomal abnormalities such as Down syndrome. While it may sometimes be an isolated normal variant, its presence warrants further evaluation. The nurse should report this finding to the provider for assessment and potential genetic follow-up.

D. Transient circumoral cyanosis.
Brief bluish discoloration around the lips in a newborn is typically due to vasomotor instability and is common when the infant is crying or cold. As long as the central mucous membranes remain pink and oxygenation is normal, this finding is not concerning and usually resolves without intervention.

A nurse should discontinue oxytocin if the client experiences uterine hyperkinesia, which is defined as more than 5 contractions in 10 minutes.

Choice B is not correct because contractions lasting 60 seconds are within the normal range.

Choice C is not correct because moderate variability of the fetal heart rate is a reassuring sign.

Choice D is not correct because nonrepetitive early decelerations are generally considered benign and do not require intervention.