A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to implement next is to complete a sterile vaginal exam (Option A). This is crucial in assessing the extent of cervical dilation and the position of the fetus to determine the progress of labor and the need for immediate interventions. Taking the maternal temperature every 2 hours (Option B) is important for monitoring signs of infection but is not the immediate priority in this situation where fetal distress is a concern. Preparing for an immediate cesarean birth (Option C) may be necessary in cases of fetal distress or other complications, but it should not be the immediate next step without further assessment through a vaginal exam. Obtaining sterile suction equipment (Option D) is important in case meconium aspiration occurs during delivery, but it is not the most immediate action needed in this scenario. Educationally, this question highlights the importance of prompt assessment and decision-making in labor and delivery situations to ensure the safety and well-being of both the mother and the baby. Understanding the significance of different assessments and interventions in such critical moments is vital for nurses working in maternal and reproductive health settings.

Correct Answer: A

Rationale: The correct answer is A) Between the time the temperature falls and rises. This temperature pattern indicates the occurrence of ovulation, which is crucial for conception. Basal body temperature typically drops just before ovulation and then rises and remains elevated after ovulation. This shift in temperature signifies the release of an egg and the fertile window for conception. Option B) Between 36 and 48 hours after the temperature rises is incorrect because ovulation usually occurs before the temperature rises, not after. Therefore, this timing would not align with the fertile window for conception. Option C) When the temperature falls and remains low for 36 hours is incorrect because a sustained low temperature does not indicate ovulation. Ovulation is typically associated with a temperature rise, not a prolonged low temperature. Option D) Within 72 hours before the temperature falls is incorrect because ovulation occurs before the temperature falls. Therefore, this timing would not align with the fertile window for conception. In an educational context, understanding basal body temperature patterns is essential for women who are trying to conceive. By tracking these patterns accurately, women can identify their most fertile days and optimize their chances of conception. Education on this topic empowers women to take control of their reproductive health and make informed decisions regarding family planning.

Correct Answer: C

Rationale: The most effective instruction to prevent nipple soreness for a breastfeeding mother is to correctly place the infant on the breast (Option C). This is crucial because proper positioning and latching ensure that the baby is effectively extracting milk without causing damage to the mother's nipples. When the baby is positioned correctly with a deep latch, nipple soreness is minimized as the baby is able to feed efficiently. Option A, wearing a cotton bra, is not directly related to preventing nipple soreness during breastfeeding. While wearing a comfortable bra is important for overall breast health, it does not address the root cause of nipple soreness. Increasing nursing time gradually (Option B) may not necessarily prevent nipple soreness. The key factor is the correct latch and positioning rather than the duration of nursing sessions. Manually expressing a small amount of milk before nursing (Option D) is not as effective as ensuring correct placement of the infant on the breast. While expressing some milk before nursing can help with engorgement or if the baby is having difficulty latching, it is not the primary method to prevent nipple soreness. In an educational context, it is vital for healthcare professionals to emphasize proper breastfeeding techniques to prevent common issues like nipple soreness. By understanding and promoting correct latch and positioning, nurses can support mothers in establishing a successful breastfeeding relationship with their infants, leading to better outcomes for both mother and baby.

Correct Answer: C

Rationale: In the context of maternal and reproductive health, the correct answer is C) The cervix is completely dilated. This is because full cervical dilation (10 cm) indicates that the cervix is fully prepared for the pushing stage of labor. At this point, the client's body is physiologically ready for the second stage of labor, which involves pushing to facilitate the birth of the baby. Option A) There is only an anterior or posterior lip of cervix left is incorrect because the presence of even a small part of the cervix that is not fully dilated can obstruct the descent of the baby and hinder the progress of labor. Option B) The client describes the need to have a bowel movement is incorrect because the urge to push due to feeling like having a bowel movement may not necessarily indicate full cervical dilation and readiness for the pushing stage of labor. Option D) The cervix is completely effaced is incorrect because cervical effacement, which refers to the thinning of the cervix, is important for labor progress but not a direct indicator of the readiness to begin pushing. In an educational context, it is crucial for nurses to understand the significance of cervical dilation in guiding the management of laboring clients. Recognizing the signs of full dilation ensures that the pushing stage commences at the appropriate time, promoting effective labor progress and optimal maternal and fetal outcomes.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) A persistent cold. This is because pediatric clients with AIDS often present with recurrent or persistent infections due to their compromised immune system. A persistent cold is a common manifestation in pediatric patients with AIDS due to their inability to fight off infections effectively. Option A) Shortness of breath is less likely to be the most common presenting symptom in a pediatric client with AIDS compared to recurrent infections like a persistent cold. While respiratory issues can occur in AIDS patients, they are not typically the initial presenting symptom. Option B) Joint pain is not a common presenting symptom of AIDS in pediatric clients. Joint pain is more commonly associated with conditions like arthritis or other rheumatologic disorders. Option D) Organomegaly (enlargement of organs) is also not typically the most likely presenting symptom in a pediatric client with AIDS. While organomegaly can occur in some cases of AIDS, it is not as common or as specific a symptom as recurrent infections like a persistent cold. Educationally, understanding the common presenting symptoms of pediatric clients with AIDS is crucial for healthcare providers working in maternal and reproductive health. This knowledge can help in early identification, timely interventions, and appropriate management of pediatric patients with HIV/AIDS, ultimately improving their outcomes and quality of life.