A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: In the context of ethical issues in maternal newborn nursing, choosing the correct action during the transition phase of labor is crucial for both the well-being of the mother and the baby. The correct answer, D) Encourage the client to use a pant-blow breathing pattern, is the most appropriate action during this phase. This breathing technique helps the mother manage pain and maintain focus during contractions, promoting relaxation and optimal oxygenation for both mother and baby. Option A) Assist the client to void every 3 hours is not a priority during the transition phase of labor. It is essential to focus on labor progress and comfort measures rather than a strict voiding schedule. Option B) Monitor contractions every 30 minutes is important, but it is a routine nursing intervention during labor and does not specifically address the client's immediate needs during the transition phase. Option C) Placing the client into a lithotomy position is not recommended during the transition phase as it can hinder the progress of labor and increase the risk of complications. Lithotomy position can lead to decreased blood flow to the baby and increase the risk of perineal tearing for the mother. Educationally, it is important for nurses to understand the physiological and psychological needs of laboring women to provide appropriate care. Encouraging the use of breathing techniques like pant-blow patterns can enhance the birthing experience by promoting relaxation and reducing stress. Nurses should be knowledgeable about evidence-based practices to support women during labor while considering ethical principles of beneficence and non-maleficence.

Correct Answer: D

Rationale: In the context of maternal newborn nursing, it is crucial for the nurse to understand the significance of laboratory results during pregnancy. In this scenario, the nurse should report a platelet count of 140,000/mm3 to the provider. Thrombocytopenia, which is a low platelet count, can be a concerning finding in pregnancy as it may lead to complications such as bleeding disorders or preeclampsia. Therefore, timely communication of this result to the provider is essential for further evaluation and management to ensure the well-being of both the mother and the unborn baby. Regarding the other options: - A) A white blood cell count of 11,000/mm3 is within normal limits and does not typically require immediate reporting. - B) A hemoglobin level of 11.2 g/dL may be slightly low but is not as concerning as a low platelet count in this context. - C) A hematocrit level of 34% is also within an acceptable range for a pregnant individual and does not warrant immediate notification to the provider. Educationally, understanding the rationale behind the importance of specific laboratory values in pregnancy equips nurses with the knowledge to prioritize and communicate critical findings effectively. It also underscores the role of the nurse in advocating for the health and safety of both the mother and the fetus by promptly identifying and addressing abnormal results.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Premature ovarian failure. Premature ovarian failure is a significant factor affecting fertility as it refers to the loss of ovarian function before the age of 40, leading to infertility due to the depletion of ovarian follicles. This condition results in decreased estrogen production and irregular or absent menstrual cycles, impacting the client's ability to conceive. Option B) Renal calculi, Option C) Dysmenorrhea, and Option D) Recurrent urinary tract infection are incorrect choices for factors affecting fertility. Renal calculi are kidney stones and do not directly impact fertility. Dysmenorrhea is severe menstrual cramps but does not necessarily affect fertility unless it is associated with an underlying condition like endometriosis. Recurrent urinary tract infections, while they can cause discomfort and complications, do not directly influence fertility unless they lead to pelvic inflammatory disease, which is not directly mentioned in the question. Educationally, understanding the factors that affect fertility is crucial for nurses working in maternal newborn care. By correctly identifying these factors, nurses can provide appropriate support, education, and referrals for clients experiencing infertility issues. It also underscores the importance of a comprehensive infertility assessment to determine the underlying causes and develop a suitable care plan for the client.

Correct Answer: A

Rationale: Rationale: The correct answer is option A) Heart disease. Terbutaline is a tocolytic medication used to inhibit preterm labor by relaxing the uterine smooth muscle. It is contraindicated in clients with heart disease due to its potential to cause cardiovascular side effects, such as tachycardia and arrhythmias. Administration of terbutaline in clients with underlying heart disease can exacerbate these conditions and pose a serious risk to the client's health. Option B) Cervical dilation of 2 cm is not a contraindication for terbutaline administration. In fact, terbutaline is often used in cases of preterm labor where cervical dilation has begun to help delay labor and allow for administration of corticosteroids to improve fetal outcomes. Option C) Gestational age of 34 weeks is not a contraindication for terbutaline use. Terbutaline can be used up to 37 weeks of gestation to delay preterm labor and allow for appropriate interventions to improve neonatal outcomes. Option D) Allergy to penicillin is unrelated to the administration of terbutaline. Allergy to penicillin would not impact the use of terbutaline in managing preterm labor. Educational context: Understanding contraindications for medications used in maternal newborn nursing is crucial for nurses caring for pregnant clients. By knowing the contraindications of medications like terbutaline, nurses can ensure safe and effective care for both the mother and the fetus. It is essential to consider the client's medical history and potential risks associated with medication administration to make informed decisions that promote positive outcomes for both the mother and the newborn.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Jitteriness as a manifestation of hypoglycemia in a newborn of a mother with gestational diabetes. Hypoglycemia occurs when the newborn's blood glucose levels are low, which can lead to symptoms like jitteriness due to the brain's sensitivity to glucose levels. Option A) Hypertonia is not typically associated with hypoglycemia but rather with conditions like cerebral palsy. Option C) Acrocyanosis is the bluish discoloration of the extremities due to poor circulation and is not directly related to hypoglycemia. Option D) Generalized petechiae is small red or purple spots on the skin caused by bleeding under the skin and is not a common manifestation of hypoglycemia in newborns. Educationally, understanding the signs and symptoms of hypoglycemia in newborns, especially those born to mothers with gestational diabetes, is crucial for nurses working in maternal newborn care. It is essential for nurses to be able to recognize these manifestations promptly to provide appropriate interventions and prevent complications associated with hypoglycemia in newborns.