A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Correct Answer: A

Rationale: Late decelerations on the fetal monitor strip indicate uteroplacental insufficiency. These decelerations occur after the peak of a contraction, and the fetus may not receive enough oxygen-rich blood during contractions. Uteroplacental insufficiency can lead to fetal hypoxia and acidosis if not addressed promptly. It is important for the nurse to take appropriate steps to improve fetal oxygenation, such as repositioning the mother, administering oxygen, and adjusting IV fluids. If late decelerations persist, further interventions may be necessary to ensure the well-being of the fetus.

Correct Answer: D

Rationale: The newborn's presentation with a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, and persisting low oxygen saturation (<87%) are indicative of respiratory distress. These signs suggest that the newborn is having difficulty breathing and may not be getting enough oxygen into their system. Respiratory distress in newborns is a serious condition that requires immediate attention and intervention to support breathing and oxygenation. It is crucial for healthcare providers to recognize and address respiratory distress promptly to prevent further complications.

Correct Answer: C

Rationale: The signs described in the scenario - jitteriness, weak high-pitched cry, irregular respirations - are indicative of hypoglycemia in a newborn. Babies born to mothers with diabetes are at risk for hypoglycemia due to their exposure to high blood sugar levels in utero. After birth, when the baby is separated from the mother's blood supply, their own insulin production may lead to a sudden drop in blood glucose levels.

Correct Answer: A

Rationale: In the context of pharmacology and maternal newborn care, administering Rh immunoglobulin to an Rh-negative mother after delivery is crucial to prevent maternal sensitization in future pregnancies. This is the primary reason for its administration. Rh immunoglobulin works by targeting and neutralizing any Rh-positive fetal blood cells that may have entered the maternal circulation during childbirth, thus preventing the mother's immune system from producing antibodies against Rh-positive blood cells. Option A is correct because sensitization occurs when an Rh-negative mother is exposed to Rh-positive fetal blood cells, leading to the production of antibodies that can harm future Rh-positive pregnancies. By administering Rh immunoglobulin, these antibodies are prevented from forming, safeguarding the health of future pregnancies. Options B, C, and D are incorrect in this context. Treating postpartum hemorrhage, reducing infection risk, and boosting the maternal immune response are important aspects of postpartum care but do not directly relate to the primary purpose of administering Rh immunoglobulin in Rh-negative mothers. Understanding the rationale behind the use of Rh immunoglobulin is essential for healthcare providers working in maternal newborn care to ensure the well-being of both the mother and future pregnancies. This knowledge underscores the importance of accurate assessment and appropriate interventions in preventing complications related to Rh incompatibility.

Correct Answer: B

Rationale: In assessing for proper latch during breastfeeding, the correct answer is B) Ensure the baby's lips are sealed around the areola. This is crucial because a good latch ensures effective milk transfer, prevents nipple pain or damage, and promotes optimal milk supply. When the baby's lips are sealed around the areola, it signifies that the baby is positioned correctly and is able to suck efficiently. Option A) Ensure the baby's nose is covered during feeding is incorrect and potentially dangerous as it can lead to suffocation. The baby's nose should remain uncovered to allow for proper breathing during feeding. Option C) Check for audible swallowing during feeding is a good indicator of effective feeding but does not directly assess the latch itself. Option D) Encourage frequent feeding attempts is important for establishing and maintaining milk supply but does not specifically address the assessment of proper latch. Educationally, understanding how to assess for proper latch is fundamental for nurses working with breastfeeding mothers and infants. It ensures optimal nutrition for the newborn, promotes bonding between mother and baby, and helps prevent breastfeeding challenges. Nurses play a critical role in supporting breastfeeding success by accurately assessing latch and providing guidance and support to mothers.