A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

Correct Answer: A

Rationale: Variable decelerations in the fetal heart rate are due to umbilical cord compression. These decelerations are characterized by an abrupt decrease in the fetal heart rate that is variable in duration, depth, and timing in relation to the uterine contraction. They can signify compression of the umbilical cord leading to transient interruption of fetal oxygen supply. It is essential for the nurse to promptly identify variable decelerations and take appropriate actions to alleviate the compression, such as repositioning the client to relieve pressure on the cord.

Correct Answer: C

Rationale: Cold stress in a newborn can lead to an increase in oxygen consumption as the body works harder to maintain a normal body temperature. By minimizing oxygen consumption, the nursing intervention aims to prevent excessive oxygen demand and help the newborn cope with the cold stress more effectively. This can be achieved through methods such as swaddling, warming equipment, and ensuring the baby's environment is appropriately heated to maintain a stable body temperature. Minimizing oxygen consumption can help conserve energy and promote overall well-being in the newborn.

Correct Answer: C

Rationale: Administering vitamin K to a newborn is crucial to prevent bleeding disorders, specifically hemorrhagic disease of the newborn. Newborns have low levels of vitamin K at birth, which puts them at risk for hemorrhagic disease, a condition that can lead to severe bleeding, including intracranial hemorrhage. Vitamin K is essential for the production of clotting factors in the liver, which help the blood to clot effectively. By giving newborns a dose of vitamin K at birth, healthcare providers can prevent potential bleeding complications and ensure the baby's health and safety. Option A, preventing anemia, is incorrect because vitamin K does not play a significant role in preventing anemia in newborns. Anemia is usually related to iron deficiency or other factors, not vitamin K. Option B, enhancing immune function, is incorrect because while vitamin K is important for overall health, its primary role in newborns is related to blood clotting and preventing bleeding disorders, not directly related to immune function. Option D, promoting growth and development, is incorrect because although vitamin K is essential for overall growth and development, its immediate priority in newborns is to prevent bleeding disorders, as deficiencies can have serious consequences. Understanding the specific role of vitamin K in newborns' health is essential for healthcare providers working in maternal newborn care to ensure the best possible outcomes for their patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Proteinuria of +2 is the most concerning finding in a 36-week pregnant client. Proteinuria is the presence of abnormal levels of protein in the urine, which can indicate underlying issues like preeclampsia, a serious condition characterized by high blood pressure and organ damage. In a pregnant woman, particularly at 36 weeks, proteinuria can be a sign of preeclampsia, which requires immediate medical attention to prevent complications for both the mother and the baby. Now, let's discuss why the other options are not as concerning: A) Braxton Hicks contractions are common and considered normal in pregnancy, especially in the third trimester. They are usually irregular, mild, and do not indicate labor. B) Frequent urination is a common symptom in pregnancy due to hormonal changes and the growing uterus putting pressure on the bladder. While it can be uncomfortable, it is not typically a cause for concern. D) Weight gain of 2 pounds in a week is within the normal range for pregnancy, especially towards the end of the third trimester when the baby is growing rapidly. Sudden excessive weight gain or swelling, however, could be a sign of preeclampsia and should be monitored. Educationally, this question highlights the importance of recognizing concerning signs and symptoms in pregnant clients, especially those that could indicate severe conditions like preeclampsia. Understanding the significance of proteinuria in this context is crucial for nurses and healthcare providers to provide timely and appropriate care to ensure the well-being of both the pregnant individual and the unborn child.

Correct Answer: C

Rationale: In the context of pharmacology and maternal newborn care, the recommended response for a pregnant client reporting decreased fetal movements is to advise monitoring for fetal heart rate decelerations (Option C). This is the correct choice because decreased fetal movements can be an early sign of fetal distress. Monitoring the fetal heart rate can provide crucial information about the well-being of the baby, helping healthcare providers assess the situation promptly and take necessary actions to ensure the safety of both the mother and the baby. Option A, encouraging the client to lie on her left side, is a common recommendation to improve blood flow to the fetus and can be helpful in certain situations. However, in the case of decreased fetal movements, monitoring the fetal heart rate is a more direct and immediate way to assess the baby's well-being. Option B, scheduling an immediate ultrasound, may be necessary in some cases of decreased fetal movements to visualize the baby and assess its condition. However, monitoring the fetal heart rate is a quicker and more accessible initial step to take in response to this situation. Option D, instructing the client to monitor movements over the next 48 hours, is not advisable when a pregnant client reports decreased fetal movements. Time is of the essence in such situations, and waiting for 48 hours without immediate assessment could pose risks to the baby's well-being. In an educational context, understanding the importance of monitoring fetal well-being and responding promptly to changes in fetal movements is crucial for healthcare providers caring for pregnant clients. This knowledge can help prevent adverse outcomes and ensure the best possible care for both the mother and the baby.