A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

Correct Answer: A

Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.

Correct Answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

Correct Answer: D

Rationale: In a postpartum client with a perineal hematoma, assessing heart rate and blood pressure is crucial as it can help determine the client's circulatory status. A perineal hematoma has the potential to cause significant blood loss leading to hypovolemia. Monitoring vital signs like heart rate and blood pressure can provide immediate information on the client's hemodynamic stability and guide further interventions if needed.

Correct Answer: A

Rationale: The most important intervention for the nurse to implement in this situation is option A, which is to provide an opportunity for the parents to hold their infant in privacy. This intervention is crucial as it allows the parents to create memories with their stillborn baby, fostering a sense of connection and closure. It also validates the reality of their loss, enabling them to begin the grieving process and start the healing journey. Option B, assisting the couple in completing a request for autopsy, may not be the most important intervention at this moment. While obtaining information about the cause of fetal demise can be valuable for closure and future family planning, the immediate emotional needs of the parents should take precedence. Option C, encouraging the couple to seek family counseling within the next few weeks, is also important for long-term support. However, in the immediate aftermath of the stillbirth, providing emotional support and facilitating the grieving process should be the primary focus. Option D, explaining the possible causes of fetal demise, is not the most appropriate intervention at this time. The parents may not be ready to process detailed medical information while they are grieving the loss of their baby. Prioritizing emotional support and allowing them to process their feelings should come first before discussing medical specifics.

Correct Answer: C

Rationale: In this scenario, the correct intervention for the nurse to implement is to assess bilateral lung sounds (Option C). This is crucial because a 6-year-old with heart failure who has gained 2 pounds in the last 24 hours may be experiencing fluid overload, leading to pulmonary congestion and potentially exacerbating the heart failure. Assessing bilateral lung sounds allows the nurse to determine if there are any signs of pulmonary edema or congestion, which are common complications of heart failure. Early detection of these issues through lung auscultation can prompt timely interventions to prevent respiratory distress and further deterioration of the child's condition. The other options are not as pertinent in this situation: - Option A, graphing the daily weight for the past week, while important for monitoring trends in weight gain or loss, does not address the immediate concern of potential respiratory distress. - Option B, decreasing the IV flow rate, could be considered if there were signs of fluid overload, but assessing lung sounds would provide more direct information about the child's respiratory status. - Option D, restricting intake of oral fluids, may be necessary in some cases of fluid overload, but assessing lung sounds would provide more immediate information about the child's respiratory status and guide further interventions. In an educational context, this question highlights the importance of clinical assessment skills in pediatric nursing, especially in managing children with complex conditions like heart failure. Nurses must be able to recognize subtle signs and symptoms of complications early to provide timely and appropriate care to pediatric patients.