A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations...Which of the following actions should the nurse take first?

Correct Answer: C

Rationale: Recurrent variable decelerations during labor can indicate umbilical cord compression, which can result in fetal hypoxia and distress. Discontinuing the oxytocin infusion is the priority in this situation as oxytocin can cause or exacerbate uteroplacental insufficiency leading to fetal distress. By discontinuing the oxytocin, the nurse can help improve fetal oxygenation and alleviate the variable decelerations. After stopping the oxytocin infusion, the nurse should continue to monitor the fetal heart rate pattern and follow the healthcare provider's orders for further management if needed.

Correct Answer: D

Rationale: The CDC recommends that women who are not up-to-date with the MMR (measles, mumps, rubella) vaccine should receive it immediately postpartum. Rubella, also known as German measles, is particularly important during pregnancy because contracting rubella during pregnancy can lead to serious complications in the baby, such as birth defects and miscarriage. By ensuring the client receives the MMR vaccine postpartum, it helps protect both the mother and any future pregnancies from the risk of rubella infection.

Correct Answer: B

Rationale: Low back pain and cramping can indicate preterm labor and should be reported immediately for further evaluation.

Correct Answer: B

Rationale: The appropriate response for the nurse to provide to the 14-year-old client who asks the best contraception method for her is to gather more information about her sexual activity first. This approach is essential in understanding the client's individual needs and situation before recommending a suitable contraceptive method. It allows the nurse to offer personalized and accurate advice based on the client's specific circumstances, rather than making assumptions or providing generic recommendations. By starting with a discussion about the client's sexual activity, the nurse can ensure that the advice given is tailored to the client's needs and preferences, promoting informed decision-making and effective contraceptive use.

Correct Answer: B

Rationale: Foul-smelling lochia may indicate an infection and requires prompt medical evaluation.