A 32-week-gravid client presents in the emergency department with severe abdominal pain, rigid abdomen, and scant dark red bleeding. The nurse should assess this client for which of the following?

Correct Answer: B

Rationale: In this scenario, option B) Enlarging abdominal girth measurements is the correct answer. This presentation of a 32-week-gravid client with severe abdominal pain, rigid abdomen, and scant dark red bleeding is concerning for a possible ruptured ectopic pregnancy or placental abruption. Enlarging abdominal girth measurements would be indicative of a potential intra-abdominal hemorrhage, which aligns with the symptoms described. Option A) Signs of pulmonary edema is incorrect because the symptoms described do not directly suggest a pulmonary issue, but rather an abdominal emergency. Option C) Hyporeflexia and confusion are not typical manifestations associated with the clinical presentation described and would not be the priority assessments in this situation. Option D) Signs of diabetic coma and ketosis are unrelated to the symptoms presented and would not be the primary concern for a gravid client with severe abdominal pain and bleeding. In an educational context, understanding the importance of assessing for specific signs and symptoms in pregnant clients presenting with abdominal pain is crucial for nurses to provide timely and appropriate care. Recognizing the significance of changes in abdominal girth measurements can aid in early detection and intervention for potentially life-threatening conditions during pregnancy. This rationale underscores the importance of critical thinking and clinical reasoning in the assessment and management of pregnant clients in emergency situations.

Correct Answer: A

Rationale: Rationale: The correct answer is A) The baby will have at least 6 wet diapers. During the first week postpartum, it is crucial for the nurse to educate the mother about signs of adequate breastfeeding and infant hydration. Monitoring diaper output is an essential indicator of infant well-being. At least 6 wet diapers per day indicate that the baby is adequately hydrated and receiving enough breast milk. Option B) The baby will have at least 6 pasty stools is incorrect because the frequency of bowel movements varies among infants, and stool consistency can change based on multiple factors, including breastfeeding. Option C) The baby will breastfeed at least 6 times is incorrect as the frequency of breastfeeding can vary greatly among infants, and it is more important to focus on the baby's cues for feeding rather than a specific number of feedings. Option D) The baby will gain at least 6 ounces is incorrect because weight gain can vary in the first week, and it is not a reliable daily indicator of successful breastfeeding. Educationally, it is crucial for nurses to provide evidence-based anticipatory guidance to support successful breastfeeding and infant care. Understanding normal infant behaviors and growth patterns helps mothers feel confident in caring for their newborns. Monitoring diaper output is a simple yet effective way to assess infant hydration and feeding adequacy.

Correct Answer: C

Rationale: The correct answer is C) Move so that her back alternately is concave and convex. This is the correct instruction for the pelvic tilt exercise as it involves tilting the pelvis to alternately flatten and arch the lower back, engaging the abdominal and back muscles to promote core strength and flexibility. This movement helps improve posture, reduce back pain, and strengthen the pelvic floor muscles, which are crucial during pregnancy and childbirth. Option A) Stand with the back of her heels and shoulders touching a wall is incorrect because this position does not facilitate the pelvic tilt exercise. Option B) Bend laterally back and forth from one side to the other is incorrect as it describes a different exercise that focuses on side-to-side movement rather than the specific pelvic tilt motion. Option D) Lie flat on her back and move her hips from side to side is also incorrect as lying flat on the back during pregnancy, especially in later stages, can restrict blood flow to the baby and should be avoided. In an educational context, it is essential for nurses to teach pregnant women safe and effective exercises like the pelvic tilt to promote their well-being and prepare their bodies for labor and delivery. Providing accurate instructions and guidance ensures that pregnant women can benefit from these exercises without risking harm to themselves or their babies.

Correct Answer: C

Rationale: In the scenario of a vaginal delivery of a macrosomic baby where the nurse midwife requests nursing assistance, the appropriate action by the nurse would be to provide suprapubic pressure (Option C). This is the correct choice because suprapubic pressure can help to facilitate the delivery of a macrosomic baby by aiding in the descent of the baby through the birth canal. Option A, estimating fetal length and weight, would not be the most immediate or helpful action to take during the delivery process. Assessing the intensity of contractions (Option B) is important but may not directly address the specific need for assisting in the delivery of a macrosomic baby. Assisting the woman with breathing (Option D) is also important but may not directly address the need for physical assistance in the delivery process. In an educational context, understanding the appropriate actions to take during different stages of labor and delivery, especially in situations such as delivering a macrosomic baby, is crucial for nurses and healthcare providers. Providing suprapubic pressure can be a critical intervention in assisting with the safe delivery of the baby and ensuring the well-being of both the mother and the infant.

Correct Answer: C

Rationale: In this scenario, the most appropriate nursing diagnosis is "Impaired urinary elimination" (Option C). This choice is correct because the client has just voided a small amount of urine after delivery, which is insufficient considering the normal expected urine output postpartum. The assessment findings of a fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra indicate a possible urinary retention issue, which aligns with impaired urinary elimination. Option A, "Impaired skin integrity," is incorrect as there is no evidence in the scenario to support this diagnosis. Option B, "Fluid volume deficit," is not the most appropriate as the client has just voided urine, suggesting the kidneys are producing urine and fluid volume is being maintained. Option D, "Toileting self-care deficit," is not the priority at this time as the main concern is the client's urinary elimination status post-delivery. Understanding the nursing diagnoses related to postpartum care is crucial for providing comprehensive care to new mothers. Impaired urinary elimination can lead to complications such as urinary retention and bladder distention, which can impact the client's recovery post-delivery. It is important for nurses to assess and address such issues promptly to prevent further complications and promote the well-being of the client.