A client on the obstetric unit is receiving IV medications per physician’s orders. On rounds the nurse notes that the client’s IV has infiltrated. Which of the following actions should the nurse perform first?

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to take first is to choose option B) Stop the infusion and remove the catheter. This is the most appropriate immediate response to an infiltrated IV as it helps prevent further harm to the patient. Stopping the infusion will prevent any more of the medication from entering the surrounding tissues, reducing the risk of tissue damage, infection, or other complications. Removing the catheter promptly is essential to prevent further infiltration and minimize the potential for adverse effects. The other options are incorrect in this context: A) Determining whether the infusion is a vesicant is important but not the immediate priority when an IV has infiltrated. C) Documenting the occurrence in the medical record is necessary but should be done after addressing the immediate issue. D) Elevating the extremity and monitoring the site can be done after removing the catheter but is not the initial step to take. In an educational context, understanding the correct response to an infiltrated IV is crucial for nurses caring for patients receiving IV medications, especially in high-risk situations like pregnancy. This knowledge ensures patient safety and prevents potential complications associated with IV therapy.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Decrease in variability. Meperidine (Demerol) is an opioid analgesic that can cross the placental barrier and affect the fetus. Opioids can lead to central nervous system depression in both the mother and the fetus, resulting in a decrease in variability on the fetal heart monitor tracing. Variability is an important indicator of fetal well-being, so a decrease in variability can be concerning. Option A) Drop in baseline heart rate is not typically associated with meperidine administration, as opioids usually do not cause a direct drop in the baseline fetal heart rate. Option B) Increase in number of variable decelerations is not a common effect of meperidine. Variable decelerations are usually associated with cord compression, not opioid administration. Option D) Rise in number of early decelerations is also not a typical response to meperidine. Early decelerations are often considered benign and are associated with head compression during contractions. It is crucial for nurses and healthcare providers to understand the effects of medications on both the mother and fetus during pregnancy to provide safe and effective care. Monitoring fetal well-being during labor is essential to ensure timely intervention if any abnormalities are detected, especially when medications like opioids are involved.

Correct Answer: D

Rationale: In this scenario, the correct question the nurse should ask the client is option D) "Do you have a headache or blurring of your vision?". This is the correct choice because the client's elevated blood pressure of 150/110, especially when compared to her previous readings, could be indicative of postpartum preeclampsia, a serious condition characterized by high blood pressure and often accompanied by headaches and visual disturbances. Option A) "Have you had a bowel movement since delivery?" is incorrect because it is not directly related to the client's elevated blood pressure and does not address the urgent need to assess for signs of preeclampsia. Option B) "Is there anything that is making you anxious about the baby?" is also incorrect as it does not address the immediate health concern of the client's high blood pressure and potential signs of preeclampsia. Option C) "When you last went to the bathroom were you bleeding heavily?" is not the most appropriate question at this time as it does not directly address the client's current blood pressure and symptoms that could indicate a serious complication like preeclampsia. In an educational context, it is crucial for nurses to be able to recognize signs and symptoms of postpartum complications, such as preeclampsia, and to ask targeted questions to assess and manage these conditions promptly. Understanding the significance of changes in vital signs and knowing which questions to ask can lead to early detection and intervention, ultimately improving maternal and neonatal outcomes.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Prolapsed cord. A prolapsed cord is a serious obstetrical emergency that occurs when the umbilical cord descends through the cervix alongside or ahead of the presenting part of the fetus. This can lead to cord compression, compromising fetal blood flow and oxygenation, resulting in fetal distress or even death. Option A) Precipitous delivery is incorrect because while the labor is progressing, there is no indication that delivery will be unusually rapid in this case. Option B) Chorioamnionitis is less likely at this moment as the focus should be on the immediate obstetric emergency of a prolapsed cord. Option C) Uteroplacental insufficiency is not the primary concern in this scenario as the fetal heart rate with average variability and variable decelerations suggests ongoing oxygenation to the fetus. Educationally, understanding obstetric emergencies like prolapsed cord is crucial for nurses and healthcare providers working in labor and delivery settings. Prompt recognition and intervention are essential to prevent adverse outcomes for both the mother and the baby. This case highlights the importance of critical thinking and quick decision-making skills in managing emergent situations during labor and delivery.

Correct Answer: C

Rationale: In this scenario, the most appropriate action by the nurse is option C: Ask the couple if they would like to hold their baby. This choice demonstrates compassionate and patient-centered care during a highly sensitive and emotionally challenging situation. Allowing the parents the opportunity to hold their baby provides them with a chance to create memories and say goodbye, which can aid in their grieving process and facilitate closure. Option A is incorrect because moving the woman to a medical unit may not address the emotional needs of the couple during this difficult time. Option B is also inappropriate as refraining from discussing the loss with the couple can lead to feelings of isolation and lack of support. Option D is not the priority at this moment as obtaining a milk suppressant for the mother does not address the immediate emotional needs of the couple. Educationally, this question highlights the importance of providing holistic care to patients, especially in emotionally charged situations like perinatal loss. It emphasizes the significance of communication, empathy, and sensitivity in nursing practice, particularly when caring for individuals experiencing grief and loss.