A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicate an understanding of the teaching?

Correct Answer: A

Rationale: The correct answer is option A: "I will check the identification badge of anyone who removes my baby from our room." This statement demonstrates an understanding of newborn safety measures by emphasizing the importance of verifying the identity of individuals to ensure the baby's security. Option B is incorrect as sharing a photo of the baby along with public birth announcements on social media can compromise the baby's safety and privacy. Option C is also incorrect as it poses a risk to the baby's safety to sleep on the bed unsupervised. Option D is incorrect as it is not standard practice for nurses to carry babies to the nursery; instead, the mother or designated family member typically accompanies the baby. In an educational context, teaching about newborn safety is crucial to prevent potential risks and harm to the infant. Educating clients on proper safety measures helps empower them to advocate for their baby's well-being and security in various healthcare settings. It is essential for expectant parents to be knowledgeable about newborn safety practices to ensure a safe and secure environment for their newborns.

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to take is to initiate seizure precautions for the client (Option B). Preeclampsia with severe features poses a significant risk of eclampsia, which is characterized by seizures. By initiating seizure precautions, the nurse is proactively ensuring the safety of the client in the event that a seizure occurs. This includes ensuring a safe environment, having emergency medications readily available, and closely monitoring the client's vital signs. Restricting protein intake (Option A) is not the priority in this situation. Adequate protein intake is important for the health of both the mother and the developing fetus. Initiating an infusion of 0.9% sodium chloride (Option C) at 150 mL/hr may exacerbate fluid overload, a concern in preeclampsia. Encouraging the client to ambulate twice per day (Option D) is not appropriate for a client with preeclampsia with severe features, as rest and close monitoring are typically recommended to prevent complications. Educationally, this question highlights the critical importance of recognizing the potential complications of preeclampsia and the necessity of prompt interventions to ensure the safety and well-being of both the mother and the unborn child. It underscores the significance of nursing interventions in managing high-risk pregnancies and the need for nurses to be vigilant in assessing and managing maternal health issues.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Excessive high-pitched cry as an indication of neonatal abstinence syndrome (NAS) in a newborn with a maternal history of methadone use during pregnancy. Neonatal abstinence syndrome occurs when a newborn experiences withdrawal symptoms from substances the mother used during pregnancy, such as opioids like methadone. The high-pitched cry is a common manifestation of NAS, indicating central nervous system irritability. This cry is often shrill, continuous, and may sound distressed. Other signs of NAS include irritability, tremors, poor feeding, vomiting, diarrhea, sweating, fever, and respiratory issues. Option A) Hyporeactivity is incorrect because NAS typically presents with hyperactivity and not hypoactivity. Option C) Acrocyanosis is a common finding in newborns and does not specifically indicate NAS. Option D) Respiratory rate of 50/min is within the normal range for a newborn and is not a specific sign of NAS. Educationally, understanding the manifestations of NAS is crucial for healthcare professionals working with newborns exposed to substances in utero. Early recognition and appropriate management of NAS are vital to ensure the well-being of these vulnerable infants. Healthcare providers should be knowledgeable about the signs and symptoms of NAS to provide timely and effective interventions for affected newborns.

Correct Answer: A

Rationale: In the context of maternal health issues in the US, it is crucial for nurses to have a solid understanding of the management of infections during labor, such as group B streptococcus (GBS) ß-hemolytic infection. The correct medication to administer in this scenario is Ampicillin. Ampicillin is the drug of choice for intrapartum prophylaxis against GBS in laboring women to prevent neonatal sepsis and other GBS-related complications. It effectively crosses the placenta and reaches therapeutic levels in both the maternal and fetal circulations, providing protection to the newborn. Azithromycin, Ceftriaxone, and Acyclovir are not the appropriate medications for treating GBS during labor. Azithromycin is not the first-line agent for GBS prophylaxis. Ceftriaxone is not typically used for GBS prophylaxis during labor. Acyclovir is used to treat herpes simplex virus infections, not GBS. This question serves as an educational opportunity for nurses to reinforce their knowledge of appropriate medication management for maternal infections during labor, emphasizing the importance of evidence-based practice in ensuring positive maternal and neonatal outcomes.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to change the client's position (Option A). Late decelerations in the fetal heart rate (FHR) indicate uteroplacental insufficiency, which could be caused by pressure on the mother's vena cava due to supine position. Changing the client's position can help relieve this pressure, improving blood flow to the placenta and potentially resolving the late decelerations. Option B, palpating the uterus to assess for tachysystole, is not the first action to take in this situation because addressing the fetal heart rate pattern is the priority. Option C, increasing the client's IV infusion rate, and Option D, administering oxygen, are important interventions but are not the initial steps when late decelerations are detected. From an educational perspective, it is crucial for nurses to prioritize interventions based on the urgency of the situation. Understanding the pathophysiology behind late decelerations and knowing the appropriate interventions can help nurses provide effective and timely care to clients in labor, ultimately improving maternal and fetal outcomes.