A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. After an examination, the provider informs the client that the fetus has died, and the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?

Correct Answer: B

Rationale: The correct answer is B: Missed miscarriage. At 11 weeks gestation, the fetus has died but has not been expelled from the uterus. This is known as a missed miscarriage. The other choices are incorrect because: A: Incomplete miscarriage involves partial expulsion of the products of conception. C: Inevitable miscarriage indicates that the miscarriage is in progress and cannot be stopped. D: Complete miscarriage refers to the complete expulsion of all products of conception from the uterus.

Correct Answer: B

Rationale: The correct answer is B because it demonstrates the client's understanding that a second vaccination is needed, which is crucial for developing adequate immunity against varicella. This statement shows comprehension of the vaccination schedule and the importance of completing the series for full protection. Option A is incorrect as it suggests the need for a second vaccination but lacks conviction. Option C is incorrect because it only states the purpose of the vaccine without addressing the need for a second dose. Option D is incorrect as it mentions testing for immunity status, which is not typically necessary after receiving the varicella vaccine.

Correct Answer: C

Rationale: Rationale: - MSAFP screening is recommended for all pregnant clients to assess risk of neural tube defects or chromosomal abnormalities. - It is a standard prenatal test regardless of specific medical conditions. - Options A, B, and D are not directly related to the indication for MSAFP screening in pregnancy.

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation. Monitoring oxygen saturation is crucial in evaluating the newborn's respiratory status post-surfactant administration. It helps assess the effectiveness of surfactant therapy in improving oxygenation. Body temperature and serum bilirubin are not directly related to assessing respiratory distress syndrome. Heart rate may be affected by various factors and may not provide specific information on respiratory status.

Correct Answer: C

Rationale: The correct answer is C: Sore nipple with cracks and fissures. This is indicative of possible breastfeeding issues like improper latch or infection, requiring prompt intervention to prevent complications. Scant, non-odorous white vaginal discharge (A) is normal postpartum lochia. Uterine cramping during breastfeeding (B) is common due to oxytocin release. Decreased response with sexual activity (D) is a common postpartum concern but not an urgent issue at 4 weeks. Addressing sore nipples promptly is crucial for successful breastfeeding and maternal well-being.

Correct Answer: C

Rationale: The correct answer is C: Erythromycin. Erythromycin is the standard treatment for preventing ophthalmia neonatorum, a condition caused by Neisseria gonorrhoeae or Chlamydia trachomatis. It is a broad-spectrum antibiotic that effectively prevents bacterial infections in newborns. Ofloxacin (A) is a fluoroquinolone antibiotic not typically used in newborns. Nystatin (B) is an antifungal medication used for treating fungal infections, not bacterial infections like ophthalmia neonatorum. Ceftriaxone (D) is a cephalosporin antibiotic used for various bacterial infections, but it is not the first-line treatment for preventing ophthalmia neonatorum.

Correct Answer: B

Rationale: The correct answer is B: Ask the client if they have thoughts of harming themselves or their infant. This is the priority because postpartum psychosis poses a risk of harm to the client and the infant. Assessing for suicidal or homicidal ideation is crucial to ensure safety. Choice A may be important but ensuring immediate safety takes precedence. Choice C is important but not the priority. Choice D may provide background information but does not address the immediate safety concern.

Correct Answer: B

Rationale: The correct answer is B: Position the client with one hip elevated. This is the priority action because the client's contractions are frequent and of significant duration, indicating active labor. Elevating one hip can help improve fetal oxygenation and blood flow during contractions. It can also help optimize fetal positioning for a smoother labor process. Choice A: Notifying the provider is important but not the priority at this moment. The nurse should first address immediate client needs. Choice C: Asking about pain medication is important, but managing the client's positioning for labor progress takes precedence. Choice D: Having the client void is a routine step in labor management but is not the priority action in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Missed miscarriage. At 11 weeks gestation, the fetus has died but has not been expelled from the uterus. This is known as a missed miscarriage. The other choices are incorrect because: A: Incomplete miscarriage involves partial expulsion of the products of conception. C: Inevitable miscarriage indicates that the miscarriage is in progress and cannot be stopped. D: Complete miscarriage refers to the complete expulsion of all products of conception from the uterus.