A client delivered a baby 2 months ago. Her partner calls into the office to report that the woman is angry, confused, and having conversations with herself. Which response by the nurse is most appropriate?

Correct Answer: A

Rationale: Option A is the correct answer because the symptoms described by the partner (anger, confusion, having conversations with herself) could indicate a serious mental health issue such as postpartum psychosis. Postpartum psychosis is a rare but severe condition that requires immediate medical attention as it can be life-threatening to both the mother and the baby. By advising the partner to take the client to the nearest emergency room for evaluation, the nurse is ensuring that the client receives the necessary urgent care and support. Option B is incorrect because simply bringing the client to the physician's office for medication may not be sufficient to address the severity of the symptoms described. Postpartum psychosis requires more immediate and intensive intervention than just medication. Option C is incorrect because outpatient care is not appropriate for someone experiencing symptoms of postpartum psychosis. This condition requires immediate and intensive treatment, which is typically not provided in an outpatient setting. Option D is incorrect because while intensive behavioral therapy may be a component of treatment for postpartum psychosis, it is not the most appropriate initial response. In this case, immediate medical evaluation in an emergency room setting is necessary to ensure the safety and well-being of the client and her baby.

Correct Answer: B

Rationale: Choice A is incorrect because a variable baseline heart rate of 140 with V-shaped decelerations to 120 unrelated to contractions is concerning. V-shaped decelerations are usually associated with cord compression, which can lead to fetal distress. Choice C is incorrect because a flat baseline heart rate of 140 with decelerations to 120 that return to baseline after the contraction indicates fetal distress. Decelerations should not drop below the baseline heart rate, and a flat baseline can suggest fetal hypoxia. Choice D is incorrect because a flat baseline heart rate of 140 with no obvious decelerations or accelerations can be indicative of fetal compromise. A lack of variability in the heart rate can be a sign of fetal distress. Choice B is the correct answer because a variable baseline heart rate of 140 with decelerations to 100 that mirror each of the contractions is considered normal. This pattern, known as early decelerations, is typically caused by head compression during contractions and is not associated with fetal distress. It is a reassuring sign of fetal well-being during labor.

Correct Answer: B

Rationale: Option A is incorrect because there is no evidence to support the statement that epidurals do not work well when the pain level is above 5. Pain is subjective, and each individual experiences pain differently. The decision to administer an epidural should be based on the patient's request and assessment of their pain level, not an arbitrary cutoff point. Option C is incorrect because it is never too late for an epidural. While it is true that the baby may be born soon in stage 2 labor, epidurals can still be administered to provide pain relief during delivery. The timing of the epidural should be based on the patient's request and pain level, not assumptions about the progression of labor. Option D is incorrect because the decision to administer an epidural should not be based on the fetal heart rate alone. Fetal heart rate monitoring is important for assessing the well-being of the baby, but it should not determine whether a patient receives pain relief. The decision to administer an epidural should be based on the patient's request and assessment of their pain level. Option B is the correct answer because the nurse should promptly respond to the patient's request for an epidural by contacting the doctor to obtain an order. It is important to advocate for the patient's preferences and provide timely pain relief during labor. Promptly contacting the doctor for an epidural order demonstrates good communication and patient-centered care.

Correct Answer: B

Rationale: During the third stage of labor, the nurse should be assessing for signs of placental separation and expulsion. Choice B, "Uterus rising in the abdomen and feeling globular," is the correct answer because this is a classic sign that the placenta is detaching from the uterine wall. As the uterus rises, it indicates that the placenta is being expelled. This assessment is crucial to ensure that the placenta is delivered in its entirety and to prevent complications such as postpartum hemorrhage. Choice A, "Fetal heart assessment after each contraction," is incorrect for the third stage of labor. Fetal heart assessment is more relevant during the first and second stages of labor when monitoring fetal well-being during contractions. In the third stage, the focus shifts to the delivery of the placenta and maternal recovery. Choice C, "Rapid cervical dilation to ten centimeters," is also incorrect during the third stage of labor. Cervical dilation typically occurs during the first stage of labor, not the third stage. By this stage, the cervix should be fully dilated, and the focus should be on the delivery of the placenta. Choice D, "Maternal complaints of intense rectal pressure," is a common sign of fetal descent during the second stage of labor, not the third stage. This sensation occurs as the baby moves down the birth canal and is a signal for the mother to start pushing. In the third stage, the mother may experience mild contractions as the placenta separates, but intense rectal pressure is not typically associated with this stage. In summary, during the third stage of labor, the nurse should assess for the rising of the uterus in the abdomen, indicating placental separation and expulsion. Fetal heart assessment, cervical dilation, and complaints of rectal pressure are not typically assessed during this stage and are more relevant to earlier stages of labor.

Correct Answer: B

Rationale: In this scenario, the woman is 40 weeks gestation, with 2 cm dilation, 30% effacement, contracting every 12 minutes and 30 seconds. The fetal heart rate is in the 140s with good variability and spontaneous accelerations. Choice A: The woman is not high risk based on the information provided. Tocolytics are used to stop preterm labor, not indicated in this case. Choice C: Induction is not necessary at this point as the woman is only 2 cm dilated and 30% effaced, indicating early labor. Choice D: The woman is not in active labor as she is only 2 cm dilated and contracting every 12 minutes and 30 seconds. Correct Answer (B): The findings suggest that the woman is in early labor. With 2 cm dilation, 30% effacement, and contractions every 12 minutes and 30 seconds, she is not in active labor. The fetal heart rate is reassuring with good variability and spontaneous accelerations. The nurse can conclude that the woman is in early labor and could potentially be sent home to continue laboring until she is in active labor. This approach allows her to be in a familiar and comfortable environment until labor progresses further.