A client at 32 weeks' gestation reports regular uterine contractions every 10 minutes. What is the nurse's priority action?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Assess for cervical changes and fetal heart rate. The priority action for a client experiencing regular uterine contractions at 32 weeks' gestation is to assess for cervical changes and fetal heart rate to determine if the client is in preterm labor. This assessment is crucial for evaluating the status of the pregnancy and determining the appropriate course of action. Option A) Administer tocolytic medication as prescribed is incorrect because administering tocolytic medication should only be done after assessing for cervical changes and confirming preterm labor. Tocolytic medication is used to inhibit uterine contractions and delay preterm birth. Option B) Performing a sterile vaginal examination is not the priority in this situation as it can potentially introduce infection and is not necessary until the assessment of cervical changes and fetal heart rate has been completed. Option D) Encouraging ambulation to relieve discomfort is not the priority when there is a concern for preterm labor. While ambulation can sometimes help alleviate discomfort, it is not the appropriate action when assessing for preterm labor. Educationally, this scenario highlights the importance of prioritizing assessments in obstetric nursing. Understanding the sequence of actions in response to signs of preterm labor is critical in providing safe and effective care to pregnant clients. Early identification and timely intervention can significantly impact outcomes for both the mother and the baby.

Correct Answer: A

Rationale: The correct answer is A) Verify signed informed consent. The priority nursing action before any invasive procedure like an amniocentesis is to ensure that the client has given informed consent. This is crucial as it upholds the principles of autonomy and beneficence, respecting the client's right to make decisions about their own healthcare. Without informed consent, the procedure cannot proceed ethically or legally. Option B) Administer prescribed analgesics is not the priority because while pain management is important for the client's comfort during the procedure, ensuring informed consent takes precedence. Option C) Encouraging the client to empty their bladder is important for the procedure but is not the priority over verifying informed consent. Option D) Positioning the client in a semi-Fowler's position is a procedural step for the amniocentesis but is not the priority before confirming informed consent. This scenario provides an important educational context about the ethical and legal responsibilities of healthcare providers in obtaining informed consent from clients before any medical procedure. It highlights the significance of respecting clients' autonomy and ensuring they have the necessary information to make informed decisions about their healthcare.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Check maternal blood pressure. When a client in labor receiving an epidural reports feeling lightheaded and nauseous, it could indicate hypotension, a common side effect of epidural anesthesia. Checking the maternal blood pressure is crucial to assess for hypotension, which can compromise both maternal and fetal well-being. Option A) Administer antiemetics as prescribed is incorrect because the priority is to address the potential hypotension first before treating the nausea. Option C) Increasing the oxytocin infusion rate is incorrect because the client is experiencing symptoms of hypotension, not related to the need for increased oxytocin. Option D) Encouraging the client to lie on her back is incorrect as this position can worsen hypotension. Educationally, understanding the potential side effects of epidural anesthesia, such as hypotension, is essential for nurses caring for laboring clients. Prompt assessment and intervention are crucial to ensure the safety of both the mother and the baby. Prioritizing interventions based on the client's condition and the potential risks involved is a fundamental aspect of maternal-newborn care.

Correct Answer: C

Rationale: In this scenario, the nurse's priority intervention should be option C: assess fetal heart rate and contraction pattern. This is the correct answer because when a client at 28 weeks' gestation reports regular uterine contractions, assessing the fetal heart rate and contraction pattern is crucial to determine the well-being of the fetus. Monitoring these parameters helps in evaluating fetal distress and the effectiveness of the contractions. It allows for timely intervention if there are signs of fetal compromise. Option A, administering tocolytic medication, is not the priority in this situation because before initiating tocolytic therapy, it is essential to assess the fetal status to determine if the contractions are causing any harm to the fetus. Performing a sterile vaginal examination (Option B) can introduce the risk of infection and should not be the immediate priority unless there are specific indications after assessing fetal well-being. Encouraging ambulation (Option D) may be helpful in some cases, but it is not the priority when the fetal well-being is in question. Educationally, this question highlights the importance of assessing fetal well-being in pregnant clients experiencing uterine contractions. It emphasizes critical thinking skills in prioritizing interventions based on the client's condition and the potential impact on fetal health. This rationale underscores the significance of accurate assessment and monitoring in maternal newborn care.

Correct Answer: B

Rationale: Headaches and nausea are common side effects of oral contraceptives. Choice A is incorrect because birth control pills typically decrease the menstrual flow. Choice C is not commonly reported with oral contraceptives, and many women report no change in libido. Choice D is incorrect because while oral contraceptives may slightly increase the risk of certain cancers, breast cancer risk is not significantly elevated compared to the general population.