A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?

Correct Answer: A

Rationale: The client who experienced a cesarean birth 4 hours ago and is reporting pain should be seen first by the nurse. Pain assessment and management are crucial following a cesarean birth to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and affect the client's recovery process. Addressing the client's pain promptly is a priority to promote their comfort and facilitate their recovery.

Correct Answer: A

Rationale: The Moro reflex is a normal infantile reflex that is typically present at birth and disappears around 4-6 months of age. This reflex is triggered by a sudden loss of support or a loud noise, causing the infant to throw back the head and extend the arms in a gesture as if trying to grab something. In a situation where the newborn's birth was prolonged due to wide shoulders, there is a higher risk of injury to the brachial plexus (nerves that control arm movement) during delivery. Damage to the brachial plexus can result in weakness or paralysis of the affected arm, and this may impact the Moro reflex as it involves the arms' movement. Therefore, the nurse would be particularly observant for any abnormality or lack of response in the Moro reflex as it may indicate potential nerve injury related to the difficult birth.

Correct Answer: B

Rationale: In the scenario where a newborn has a heart rate below 100 bpm immediately after birth, the correct first action is to administer oxygen and provide stimulation (Option B). This is based on the principle of supporting the newborn's transition to extrauterine life and addressing potential causes of bradycardia. Administering oxygen helps improve oxygenation, which is crucial for the newborn's vital functions, especially if there is inadequate oxygen supply causing the low heart rate. Providing stimulation, such as rubbing the baby's back or flicking the soles of the feet, can help increase the heart rate through sensory input. The other options are not the first-line interventions in this situation. Providing chest compressions (Option A) is not appropriate as the newborn's heart rate is only slightly below the expected range, and chest compressions are indicated for severe bradycardia or cardiac arrest. Delaying interventions and reassessing in 5 minutes (Option C) could lead to a critical delay in addressing potential issues with oxygenation and perfusion. Starting an IV line for medications (Option D) is not the initial step and should be considered only if other measures fail to improve the newborn's condition. In an educational context, understanding the immediate actions in response to abnormal findings in newborns is crucial for nurses and healthcare providers working in maternal newborn care. This knowledge ensures timely and appropriate interventions to support the newborn's transition and promote positive outcomes in the neonatal period.

Correct Answer: C

Rationale: In preparing a mother for epidural anesthesia, the nurse's role includes ensuring the mother is in a supine position (Option C). This position allows for proper placement of the epidural catheter in the lower back, facilitating accurate administration of anesthesia into the epidural space. Option A, monitoring contractions, is not directly related to the preparation for epidural anesthesia. This task typically falls under the domain of assessing labor progress and fetal well-being. Option B, ensuring the mother has an empty bladder, is important for epidural placement but is not solely the nurse's responsibility. It is crucial for the mother's comfort during the procedure and to prevent urinary retention post-anesthesia. Option D, administering a test dose of the epidural medication, is typically the responsibility of the anesthesia provider, not the nurse. This test dose is crucial to assess for any adverse reactions or inadvertent intravascular or intrathecal placement of the catheter. In the context of maternal newborn nursing, understanding the nurse's role in preparing a mother for epidural anesthesia is vital for safe and effective pain management during labor. Nurses play a key role in ensuring proper positioning, advocating for patient comfort and safety, and facilitating communication between the healthcare team and the mother.

Correct Answer: B

Rationale: In the context of a newborn with a positive Coombs test, the priority action is to monitor for jaundice progression, which is option B. This is because a positive Coombs test indicates the presence of antibodies on the newborn's red blood cells, which can lead to hemolysis and subsequent jaundice. Monitoring for jaundice progression allows healthcare providers to assess the severity of the condition and determine if further interventions are needed. Option A, beginning phototherapy immediately, is not the priority action because phototherapy is typically initiated based on the level of bilirubin in the newborn's blood, not solely on the basis of a positive Coombs test. Option C, administering immunoglobulin therapy, is not the priority action for a positive Coombs test. While immunoglobulin therapy may be indicated in certain cases of hemolytic disease of the newborn, it is not the initial priority when managing a newborn with a positive Coombs test. Option D, initiating exchange transfusion procedures, is a more invasive and aggressive intervention that is typically reserved for severe cases of hyperbilirubinemia that do not respond to other treatments. It is not the initial priority action when dealing with a positive Coombs test in a newborn. In maternal newborn nursing, understanding the implications of a positive Coombs test and the appropriate interventions is crucial for providing safe and effective care to newborns at risk for hemolytic disease. Monitoring for jaundice progression allows for timely interventions and prevents complications associated with severe hyperbilirubinemia.