A client in labor with a breech presentation is scheduled for a cesarean delivery. What is the nurse's priority action?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Ensure signed informed consent is on file. The priority action before any procedure, especially a cesarean delivery, is to ensure that the patient has provided informed consent. This is crucial because it upholds the principles of autonomy and ensures that the patient is aware of the risks, benefits, and alternatives to the procedure. Option A) Obtain baseline maternal vital signs is important but not the priority when compared to ensuring informed consent. Vital signs can be obtained after ensuring the patient's readiness for the procedure. Option B) Assisting with positioning for spinal anesthesia is also important for the procedure but is not as critical as confirming informed consent. Option C) Verifying fetal heart tones before the procedure is essential, but it should not take precedence over ensuring informed consent. Educationally, this question highlights the significance of informed consent in healthcare practice. It emphasizes the nurse's role in advocating for the patient's right to make informed decisions about their care. By prioritizing informed consent, nurses demonstrate respect for the patient's autonomy and uphold ethical standards in healthcare delivery.

Correct Answer: C

Rationale: In the context of preparing a client for cesarean delivery, the priority nursing action is to verify signed informed consent (Option C). This is crucial because it ensures that the client has been informed about the procedure, its risks, benefits, and alternatives, and has given their voluntary consent. Without valid informed consent, proceeding with the surgery would be ethically and legally inappropriate. Obtaining baseline vital signs (Option A) is important but not the priority in this scenario where ensuring informed consent takes precedence. Inserting an indwelling urinary catheter (Option B) is typically done after the client has been prepared for surgery and is in the operating room. Administering prophylactic antibiotics (Option D) is important in preventing infection but is not the immediate priority compared to ensuring informed consent. Educationally, this question highlights the significance of informed consent in healthcare decision-making. It underscores the nursing responsibility to advocate for patients' rights and autonomy, ensuring they are fully informed and actively participate in their care. Understanding the prioritization of actions in maternal newborn care, especially before surgical interventions, is vital for safe and ethical practice.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Check the client's blood pressure. The priority nursing action in a pregnant client experiencing headaches and blurred vision in the third trimester is to assess their blood pressure to rule out preeclampsia, a serious condition characterized by high blood pressure and organ damage. Checking the client's blood pressure is crucial as preeclampsia can lead to severe complications for both the mother and baby if left untreated. Assessing the fetal heart rate (option B) is important but not the priority when the mother's health is at risk. Administering acetaminophen (option C) may provide symptomatic relief but does not address the underlying cause. Encouraging rest (option D) is beneficial, but not the priority when potentially dealing with a hypertensive emergency like preeclampsia. Educationally, this question highlights the importance of recognizing signs and symptoms of preeclampsia in pregnant clients and the critical role of the nurse in early detection and intervention to prevent adverse outcomes for both the mother and fetus.

Correct Answer: C

Rationale: Rationale: The correct answer is C) It reduces the risk of neural tube defects. Folic acid is crucial during pregnancy as it plays a vital role in the development of the baby's neural tube, which later becomes the brain and spinal cord. Adequate folic acid intake, especially in the early stages of pregnancy, significantly decreases the risk of neural tube defects such as spina bifida and anencephaly. Option A) It helps prevent gestational diabetes is incorrect because folic acid does not have a direct relationship with preventing gestational diabetes. Gestational diabetes is more influenced by factors like diet, exercise, and maternal health. Option B) It promotes fetal brain development is partially correct, as folic acid does contribute to brain development, but its primary role is in preventing neural tube defects. Option D) It increases maternal energy levels is incorrect as folic acid does not function to directly increase energy levels. Energy levels are influenced by factors like nutrition, rest, and overall health during pregnancy. Educationally, it is important for nurses to understand the specific roles of nutrients during pregnancy to educate and support expectant mothers in making informed choices for a healthy pregnancy outcome. Understanding the significance of folic acid in preventing birth defects empowers healthcare providers to emphasize its importance in prenatal care.

Correct Answer: A

Rationale: The patient should be informed that emergency contraception is a temporary measure and they need a long-term contraceptive plan. Choice B, while important for overall sexual health, is not the priority immediately after administering emergency contraception. Choice C is not necessary unless there are complications or a follow-up consultation is needed. Choice D about drinking fluids is unnecessary and not specific to the effectiveness of emergency contraception.