A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

Correct Answer: D

Rationale: Correct Answer: D - Assist the client to turn onto her side. Rationale: 1. Side-lying position improves placental perfusion and circulation, optimizing blood pressure. 2. This position also helps in relieving pressure on major blood vessels, preventing hypotension. 3. It is a non-invasive intervention that can be quickly implemented in the labor setting. Summary of Other Choices: A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading. B: Assisting the client to an upright position may further decrease blood pressure and compromise perfusion. C: Immediate vaginal delivery is not warranted solely based on the client's blood pressure and cervical dilation.

Correct Answer: C

Rationale: Correct Answer: C - Have the client urinate. Rationale: 1. Displacement to the right of midline indicates a full bladder pushing the fundus. 2. A full bladder can prevent the fundus from contracting properly. 3. Having the client urinate will help the bladder empty, allowing the fundus to contract effectively and prevent complications like postpartum hemorrhage. Summary of Incorrect Choices: A: Massaging the fundus is not necessary as it is already firm. B: Inserting a urinary catheter is invasive and should be avoided unless necessary. D: Administering an analgesic is not indicated for fundus displacement; addressing the full bladder is the priority.

Correct Answer: C

Rationale: The correct answer is C. Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes. Vitamin K is essential for blood clotting, and newborns have lower levels at birth. Without enough vitamin K, newborns are at risk of bleeding issues. Giving them a vitamin K injection helps prevent potential bleeding disorders. Choice A is incorrect because vitamin K is not given for digestion or fat absorption. Choice B is incorrect as erythromycin ointment is used for preventing eye infections, not related to vitamin K injections. Choice D is incorrect as vitamin K does not substitute for vitamin C, and it is not primarily for strengthening the immune system.

Correct Answer: B

Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.

Correct Answer: C

Rationale: The correct answer is C because lethargy, poor perfusion, and apnea are classic signs of neonatal sepsis. Lethargy indicates decreased activity and responsiveness, poor perfusion suggests inadequate blood circulation, and apnea is a serious respiratory issue. These signs indicate a systemic infection affecting multiple organs. Choices A, B, and D do not align with typical symptoms of neonatal sepsis. Tachypnea, poor feeding, and temperature instability (Choice A) are more general and can be seen in various conditions. Increased alertness, reduced crying, and stable vitals (Choice B) are not indicative of sepsis, as sepsis typically causes the opposite. Hyperthermia, bradycardia, and cyanosis (Choice D) can be present in sepsis, but they are not as specific or as common as the signs in Choice C.