A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Correct Answer: C

Rationale: The gate control theory of pain proposes that non-painful input can close the "gates" to painful input, which helps to control and reduce pain perception. Massage, such as massaging the client's back, is a non-pharmacological intervention that can help close the gates and reduce the perception of pain. By massaging the client's back, the nurse is applying this theory to help manage the client's labor pain. Administering analgesic medication (Choice A) is a pharmacological intervention and not specifically related to the gate control theory. Choices B and D are also beneficial nursing actions but do not directly relate to the gate control theory of pain.

Correct Answer: B

Rationale: The correct response, option B, "It is molding caused by the pressure during birth and will disappear in a few days," is the most appropriate because it accurately addresses the mother's concerns about the baby's head shape. During birth, the baby's head may undergo molding due to the pressure exerted on it as it passes through the birth canal. This molding can lead to a temporary change in the shape of the baby's head. It is a normal physiological process and typically resolves within a few days as the baby's skull bones are flexible and can shift to accommodate the birth process. Option A, "You don't need to worry about it. It is perfectly normal after birth," is incorrect because it dismisses the mother's concerns without providing her with a proper explanation. Option C, "I will report it to the physician and recommend a diagnostic scan," is unnecessary as molding of the head is a common occurrence after birth and does not typically require diagnostic imaging. Option D, "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks," is incorrect as it describes a different condition known as cephalohematoma, which is not the cause of a "cone head" appearance. In an educational context, it is essential for nurses to provide accurate and reassuring information to parents regarding newborn care and common postpartum changes. Understanding the normal variations in newborn appearance can help alleviate parental anxiety and promote bonding between parents and their newborn. Educating parents about molding of the head can empower them to care for their newborn confidently during the early postpartum period.

Correct Answer: A

Rationale: The large black and blue areas on the buttocks and legs of the newborn are likely Mongolian spots. Mongolian spots are common in infants with dark skin and are not a result of birth trauma. They are benign birthmarks caused by pigment that did not make it to the top layer of the skin before birth. These spots typically fade over time and may disappear completely within a few years. It is important to educate parents about Mongolian spots to alleviate any concerns they may have about their baby's skin markings.

Correct Answer: A

Rationale: In the case of a newborn born to a mother with gestational diabetes, the nurse would most likely monitor for hypoglycemia. This is because the newborn may have been exposed to high levels of glucose in utero, leading to increased insulin production. After birth, the abrupt cessation of maternal glucose supply can result in hypoglycemia in the newborn as their insulin levels remain elevated. Monitoring blood glucose levels is crucial to prevent complications associated with hypoglycemia in these infants, such as seizures or long-term neurological damage. The other options can be ruled out based on the following explanations: - Hyperthermia is not typically associated with gestational diabetes in newborns. - Jaundice may occur in newborns for various reasons, but it is not directly linked to gestational diabetes. - Respiratory alkalosis is not a common complication of gestational diabetes in newborns. From an educational standpoint, understanding the impact of maternal health conditions on newborns is crucial for nurses working in maternal newborn care. This knowledge helps them anticipate potential complications, provide appropriate monitoring and interventions, and ensure the best outcomes for both mother and baby. In the context of gestational diabetes, vigilance for hypoglycemia in the newborn is essential to promote early detection and management of this common complication.

Correct Answer: C

Rationale: In the scenario of a mother experiencing severe vaginal bleeding during labor, the initial action of administering oxygen at 10L/min via a mask (Option C) is the correct choice. Oxygen therapy helps to improve oxygenation to both the mother and the fetus, stabilizing their conditions in cases of hemorrhage. This intervention supports tissue perfusion and minimizes the risk of hypoxia, which is crucial in a situation of acute blood loss. Monitoring vital signs and providing IV fluids (Option A) is important, but oxygenation takes precedence in addressing the immediate threat of hypoxia. Positioning the mother on her left side (Option B) can help improve blood flow to the placenta but is not the initial priority in managing severe vaginal bleeding. Preparing for an immediate cesarean section (Option D) may be necessary if other interventions fail, but it is not the first step in managing maternal hemorrhage. Educationally, this question highlights the importance of quick and appropriate interventions in emergency obstetric situations. Understanding the rationale behind each option helps nurses and healthcare providers prioritize care effectively to ensure the best outcomes for both the mother and the baby. It emphasizes the significance of rapid assessment and intervention in maternal and newborn care to address potentially life-threatening complications.