A client’s vital signs during labor and delivery were: BP 100/58–110/66, T 98.6ºF–98.8ºF, P 72–80 bpm, R 20–24 rpm. The client’s vitals 2 hours postpartum are BP 100/56, TPR 99.4ºF, P 70 bpm, R 20 rpm. Which of the following actions should the nurse perform at this time?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to perform at this time is to check the client’s lochia flow (Option A). This is the most appropriate response because assessing lochia flow is crucial in the postpartum period to monitor for signs of excessive bleeding, which could indicate postpartum hemorrhage—a common complication after childbirth. Option B, asking the client if she is having chills, is incorrect in this situation as the vital signs provided do not indicate any signs of infection or sepsis, which are typically associated with chills. Option C, encouraging the client to drink fluids, is also not the priority at this time as the client's vital signs are stable and do not suggest dehydration or hypovolemia. Option D, assessing the client’s lung fields, is not necessary based on the information provided. The client's vital signs do not suggest any respiratory distress or lung-related issues. In an educational context, understanding the significance of monitoring vital signs and assessing postpartum clients is essential for nurses working in labor and delivery or postpartum units. This question highlights the importance of recognizing postpartum complications such as postpartum hemorrhage and the role of ongoing assessment in providing quality postpartum care.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) When gastric aspirate is removed from the tube. This is because the presence of gastric aspirate confirms that the tube is in the stomach, which is the intended location for an orogastric gavage tube. Option B) When the baby suckles on the tubing is incorrect because a baby suckling on the tubing does not provide a reliable indication of proper tube placement. It can be a dangerous assumption to rely on the baby's action to determine tube location. Option C) When respirations are unlabored during tube insertion is incorrect as it does not directly correlate with tube placement. Unlabored respirations indicate the baby's overall respiratory status, not tube location. Option D) When the tubing can be inserted no farther is incorrect because the length of insertion does not guarantee correct placement. It's important to verify the tube location through appropriate means like aspirating gastric contents. In the educational context, it is crucial for nurses to understand the importance of verifying tube placement using evidence-based methods to ensure the safety and well-being of the preterm baby. Proper tube placement is essential to prevent complications such as aspiration and ensure effective delivery of nutrition or medication. Nurses must follow established protocols and guidelines to confirm tube placement accurately.

Correct Answer: A

Rationale: The correct answer is A) Nothing, because this is an acceptable weight loss. In the first few days after birth, it is common for newborns to lose up to 10% of their birth weight. This weight loss is mainly due to the loss of excess fluid and meconium. In the case of this 4-day-old neonate who has lost 286 grams (which is within the expected range), there is no cause for alarm. Option B) Advise the mother to stop breastfeeding and give formula is incorrect because breastfeeding should be continued as it provides numerous health benefits to both the baby and the mother. Formula feeding is not necessary in this situation. Option C) Notify the neonatologist of the excessive weight loss is incorrect because the weight loss described is within the normal range for a newborn. There is no need to escalate the situation to the neonatologist. Option D) Give the baby dextrose water between breast feedings is incorrect because there is no indication to provide dextrose water to a newborn who is breastfeeding and experiencing normal weight loss. Introducing unnecessary supplements can disrupt breastfeeding and may not be beneficial. In an educational context, understanding the normal weight changes in newborns is crucial for healthcare providers working with infants and new mothers. Educating nurses and caregivers about expected weight loss in neonates can help prevent unnecessary interventions and promote successful breastfeeding practices.

Correct Answer: C

Rationale: In the immediate postpartum period, the priority nursing care goal for a client who had a vaginal delivery 2 hours earlier is to monitor and ensure a moderate lochial flow (Option C). Lochia is the vaginal discharge after childbirth, and assessing its amount, color, and odor is crucial in detecting signs of excessive bleeding or infection, which are common postpartum complications. Monitoring for a moderate flow indicates that the uterus is contracting well and decreasing the risk of hemorrhage, a critical concern in the early postpartum period. Option A, breastfeeding every 2 hours, is important for bonding and infant nutrition but is not the highest priority within the first few hours after delivery. Option B, consuming a nutritious diet, is important for recovery but is not as immediate a concern as monitoring for postpartum complications. Option D, ambulation, is beneficial for preventing complications such as deep vein thrombosis but is not as critical as ensuring proper uterine contraction and assessing for excessive bleeding. Educationally, this question highlights the importance of prioritizing nursing care goals based on the immediate needs of postpartum clients to ensure optimal outcomes and prevent complications in the early postpartum period. Understanding the significance of monitoring lochial flow can help students and healthcare providers provide safe and effective care to postpartum clients.

Correct Answer: C

Rationale: In this scenario, the correct nursing diagnosis is "C) Risk for fetal injury." This choice is appropriate because uncontrolled maternal diabetes poses significant risks to the developing fetus. High glucose levels in the mother can lead to fetal macrosomia (large birth weight), congenital anomalies, hypoglycemia at birth, and other complications that can harm the fetus during pregnancy and delivery. Option A, "Altered maternal skin integrity," is not the most appropriate diagnosis in this case as the primary concern is the potential harm to the fetus due to uncontrolled maternal diabetes, rather than skin integrity issues in the mother. Option B, "Deficient maternal fluid volume," is not the most suitable diagnosis at this time as the information provided does not suggest any immediate concerns related to maternal fluid volume that would outweigh the risk to the fetus posed by uncontrolled diabetes. Option D, "Fetal urinary retention," is not the correct diagnosis based on the information provided. While diabetes can lead to complications affecting the fetus, urinary retention specifically is not a common issue associated with uncontrolled diabetes during pregnancy. Educationally, understanding the importance of monitoring and managing diabetes in pregnancy is crucial for nurses caring for pregnant women with diabetes. Recognizing the potential risks to both the mother and the fetus allows for timely interventions and preventive measures to optimize outcomes for both. It highlights the need for close monitoring, patient education, and interprofessional collaboration to ensure the best possible care for pregnant women with diabetes.