A client is being cared for 2 hours after a spontaneous vaginal birth and has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?

Correct Answer: A

Rationale: The correct answer is A: Palpate the client's uterine fundus. Palpating the uterine fundus is crucial to assess for uterine atony, a common cause of postpartum hemorrhage. If the fundus is boggy or deviated, it indicates uterine atony and immediate interventions are needed. B: Assisting the client to a bedpan to urinate is important, but addressing the potential cause of excessive bleeding takes precedence. C: Administering oxytocic medication may be necessary to help stimulate uterine contractions, but assessing the fundus comes first to determine the underlying cause of bleeding. D: Increasing fluid intake is not the priority in this situation. Palpating the fundus and addressing potential hemorrhage are the immediate concerns.

Correct Answer: C

Rationale: The correct answer is C because the indirect Coombs test is used to detect Rh-positive antibodies in the mother's blood. In this scenario, the mother is Rh-negative, so if she has been sensitized to Rh-positive blood during childbirth, her immune system may produce antibodies that could potentially harm future Rh-positive pregnancies. This test helps identify the presence of these antibodies early on so appropriate interventions can be initiated to prevent hemolytic disease of the newborn. Choices A, B, and D are incorrect: A: This test does not determine if kernicterus will occur in the newborn. Kernicterus is a severe complication of jaundice, which may result from hemolytic disease of the newborn if untreated. B: The indirect Coombs test does not detect Rh-negative antibodies in the newborn's blood. It specifically looks for Rh-positive antibodies in the mother's blood. D: The test does not determine the presence of maternal antibodies in the newborn's blood. It focuses on detecting antibodies in

Correct Answer: B

Rationale: The correct answer is B: Nipple line. This landmark is used for measuring newborn chest circumference as it ensures consistency in measurement and is a reliable reference point. The nipple line is anatomically consistent and easily identifiable, making it the ideal landmark for accurate measurements. Rationale: A: Sternal notch is not recommended for chest circumference measurement in newborns as it is not a consistent landmark and may vary among individuals. C: Xiphoid process is not suitable for chest circumference measurement as it is located at the lower end of the sternum and not commonly used for this purpose. D: Fifth intercostal space is not a recommended landmark for chest circumference measurement in newborns as it is not as reliable and consistent as the nipple line.

Correct Answer: C

Rationale: The correct answer is C: Assess the odor of the amniotic fluid. This is the appropriate nursing action because the woman is at risk for chorioamnionitis due to the elevated temperature and ruptured membranes. Assessing the odor of the amniotic fluid can help in identifying signs of infection, as foul-smelling amniotic fluid may indicate chorioamnionitis. This can guide further interventions and management, such as initiating antibiotics. Choice A is incorrect as waiting 4 hours to recheck the temperature can delay necessary interventions for potential infection. Choice B is also incorrect as administering glucocorticoids is not the immediate priority in this situation. Choice D is incorrect as preparing for an emergency cesarean section is not warranted solely based on the client's temperature and ruptured membranes without further assessment for infection.

Correct Answer: A

Rationale: The correct answer is A. Rubella immunization should be given shortly after giving birth to prevent any potential harm to the fetus during pregnancy. Immunization during pregnancy is contraindicated to avoid any risk of harm to the developing baby. Option B is incorrect as immunization in the third trimester can still pose a risk to the fetus. Option C is incorrect as immediate immunization during pregnancy is not recommended. Option D is incorrect as waiting until the next attempt to get pregnant does not protect the current fetus.