A nurse is instructing a client who is takingan oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following?

Correct Answer: C

Rationale: Shortness of breath is a potential danger sign that should be reported to the healthcare provider when taking oral contraceptives. It could indicate a serious side effect such as a blood clot in the lungs, also known as a pulmonary embolism, which can be a life-threatening condition. Therefore, it is important for the client to seek medical attention immediately if they experience sudden shortness of breath while on oral contraceptives. Reduced menstrual flow, breast tenderness, and headaches are common side effects of oral contraceptives and are not usually considered danger signs that require immediate medical attention.

Correct Answer: A

Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. Saturating two perineal pads with blood in a 30-minute period after childbirth is indicative of excessive postpartum bleeding, also known as postpartum hemorrhage (PPH). Palpating the uterine fundus helps the nurse assess for uterine atony, a common cause of PPH. If the fundus is boggy or not firm, it indicates that the uterus is not contracting effectively to control bleeding, which can lead to further complications if not addressed promptly. Once uterine atony is identified, other interventions such as administering oxytocic medications can be initiated to help the uterus contract and control bleeding.

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.