A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: The described scenario suggests the presence of late decelerations, which occur when uteroplacental insufficiency leads to decreased fetal oxygenation. In this case, the late decelerations are evident with each contraction, indicating a potential adverse reaction to the oxytocin infusion. The appropriate action would be to discontinue the infusion of IV oxytocin to prevent further compromise to fetal well-being. Alternatively, the nurse should consider repositioning the mother, administering oxygen via a face mask, and notifying the healthcare provider for further assessment and interventions.

Correct Answer: A

Rationale: - A. An 18-hour post-term, breast-fed neonate with jaundice would be a good assignment for the pediatric nurse because a neonate with jaundice requires close monitoring of bilirubin levels and feeding patterns. Breastfeeding can also affect jaundice levels, so the nurse can provide education and support to ensure successful breastfeeding and manage jaundice effectively.

Correct Answer: A

Rationale: In the context of a newborn experiencing respiratory distress, the priority nursing intervention is to administer oxygen and properly position the newborn (Option A). This is crucial because respiratory distress can lead to hypoxia, which can be life-threatening in newborns. Providing oxygen helps improve oxygenation and alleviate respiratory distress, while positioning the newborn helps optimize air exchange and lung expansion. Suctioning the airway and providing stimulation (Option B) may be necessary in certain situations to clear the airway, but in a newborn with respiratory distress, ensuring adequate oxygenation takes precedence over airway clearance. Starting IV antibiotics (Option C) is not the priority in this scenario unless there is a confirmed infection contributing to the respiratory distress. Monitoring heart rate and blood pressure (Option D) is important but is not the immediate priority when the newborn is struggling to breathe. In an educational context, understanding the prioritization of nursing interventions in newborn care is crucial for ensuring positive patient outcomes. Nurses need to be able to quickly assess and prioritize care for newborns experiencing respiratory distress to provide timely and effective interventions. This rationale emphasizes the importance of prioritizing oxygenation and positioning in newborns with respiratory distress to support their respiratory function and overall well-being.

Correct Answer: B

Rationale: The most appropriate intervention for a mother with mastitis is to encourage continued breastfeeding (Option B). This is because breastfeeding helps to clear the blocked ducts and promote drainage, which can help alleviate the symptoms of mastitis. Additionally, breastfeeding helps maintain milk production and prevents engorgement, which can worsen the condition. Advising the mother to stop breastfeeding temporarily (Option A) is not the best choice as it can lead to further complications like engorgement and decreased milk supply. Applying cold compresses (Option C) may provide some relief for symptoms like pain and swelling, but it does not address the underlying issue of blocked ducts. Referring the mother to a lactation consultant (Option D) can be helpful in providing support and guidance for proper breastfeeding techniques, but it is not the most immediate or direct intervention needed for mastitis. In an educational context, it is important to understand the physiological benefits of breastfeeding in cases of mastitis. Encouraging continued breastfeeding not only helps in resolving the current issue but also promotes bonding between the mother and baby. It is crucial for healthcare providers to have a good understanding of the management strategies for mastitis to provide optimal care for breastfeeding mothers.

Correct Answer: B

Rationale: In the scenario of a newborn experiencing apnea, the most appropriate nursing action is to administer oxygen and stimulate the newborn (Option B). This is because apnea in a newborn can lead to decreased oxygen levels in the blood, which can be detrimental to their health. Administering oxygen helps to improve oxygenation and support respiratory function, while stimulation can help to arouse the newborn and potentially restore breathing. Placing the newborn in a prone position (Option A) is not recommended as it can increase the risk of sudden infant death syndrome (SIDS) in infants. Placing the newborn under a radiant warmer (Option C) may help maintain body temperature but does not directly address the issue of apnea. Initiating chest compressions immediately (Option D) is not indicated unless the newborn is in cardiac arrest, which is a different emergency situation from apnea. In an educational context, it is crucial for nurses to be able to quickly identify and respond to newborns experiencing apnea as it can be a life-threatening condition. Understanding the appropriate interventions, such as administering oxygen and providing stimulation, is essential in providing safe and effective care to newborns in distress. Regular training and competency in neonatal resuscitation protocols are essential for healthcare providers working in maternal-newborn settings.