A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 mL in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. Which of the following nursing diagnoses is appropriate at this time?

Correct Answer: C

Rationale: In this scenario, the most appropriate nursing diagnosis is "Impaired urinary elimination" (Option C). This choice is correct because the client has just voided a small amount of urine after delivery, which is insufficient considering the normal expected urine output postpartum. The assessment findings of a fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra indicate a possible urinary retention issue, which aligns with impaired urinary elimination. Option A, "Impaired skin integrity," is incorrect as there is no evidence in the scenario to support this diagnosis. Option B, "Fluid volume deficit," is not the most appropriate as the client has just voided urine, suggesting the kidneys are producing urine and fluid volume is being maintained. Option D, "Toileting self-care deficit," is not the priority at this time as the main concern is the client's urinary elimination status post-delivery. Understanding the nursing diagnoses related to postpartum care is crucial for providing comprehensive care to new mothers. Impaired urinary elimination can lead to complications such as urinary retention and bladder distention, which can impact the client's recovery post-delivery. It is important for nurses to assess and address such issues promptly to prevent further complications and promote the well-being of the client.

Correct Answer: D

Rationale: In the context of pharmacology education, understanding the cardinal moves of labor is crucial as certain medications can impact labor progression. The correct chronological order of the cardinal moves of labor is D) Internal rotation, A) External rotation, B) Flexion, and C) Extension. The correct answer, D) Internal rotation, occurs when the fetus rotates to align its head with the mother's pelvis, facilitating descent through the birth canal. This move is essential for the optimal passage of the baby during childbirth. Option A) External rotation typically follows internal rotation and involves the fetus rotating further as it moves through the birth canal. This move helps the baby's shoulders navigate the maternal pelvis. Option B) Flexion is when the baby's head flexes towards its chest, allowing the smallest diameter of the head to present first during delivery, aiding in the passage through the birth canal. Option C) Extension is the final move where the baby's head extends as it emerges from the birth canal, enabling the rest of the body to follow smoothly. Understanding the sequence of these cardinal moves is vital for healthcare providers involved in labor and delivery to monitor the progress of labor, anticipate potential complications, and intervene appropriately if necessary. Pharmacology students should grasp this concept to appreciate how medications may impact the natural process of labor and delivery.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Ask the client directly about how she sustained her injuries. This is because when a nurse suspects that a woman is being abused by her partner, it is crucial to directly address the issue and provide an opportunity for the woman to disclose information about the abuse. By asking the client directly, the nurse can open up a dialogue, express concern for her well-being, and offer support and resources. Option B) Counsel the client on how her behavior probably provoked the attack is incorrect and harmful as it blames the victim for the abuse, which is never acceptable. Victim blaming can further traumatize the woman and discourage her from seeking help. Option C) Inform the client that the police must arrest her partner is incorrect as it may not be safe or feasible for the woman to involve the police at that moment. Safety of the woman should be the top priority, and decisions regarding involving law enforcement should be made with her consent and safety in mind. Option D) Give the client a pamphlet with the names of matrimonial attorneys is also incorrect as it does not address the immediate safety concerns of the woman. Providing legal resources should come after ensuring the woman's safety and well-being are secured. In an educational context, it is essential to teach healthcare professionals the importance of recognizing and responding to signs of intimate partner violence sensitively and effectively. Nurses should be trained to approach these situations with empathy, understanding, and a focus on the well-being and safety of the woman. Direct communication and offering support and resources are key components of providing appropriate care in cases of suspected abuse.

Correct Answer: A

Rationale: In the context of pharmacology and pregnancy assessment, understanding the implications of the baby's position in the pelvis during labor and delivery is crucial. The correct answer is A) Cephalopelvic disproportion. This occurs when the baby's head is too large or the pelvis is too small, leading to difficulties in the birthing process. It can result in prolonged labor, increased risk of instrumental delivery, and potential birth injuries. Option B) Placental abruption is incorrect in this scenario as it refers to the premature separation of the placenta from the uterine wall, not related to the baby's position in the pelvis. Option C) Breech presentation involves the baby being positioned feet or buttocks first instead of head first, which is a different scenario from the baby entering the pelvis in the LMP position. Option D) Acute fetal distress can occur due to various reasons during labor, but it is not directly tied to the baby's positioning in the pelvis. Understanding these complications is essential for healthcare providers involved in labor and delivery to anticipate and manage potential risks effectively. Pharmacological interventions may also be impacted by the progress and complications of labor, emphasizing the importance of a comprehensive understanding of pregnancy assessment factors.

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to take first is to choose option B) Stop the infusion and remove the catheter. This is the most appropriate immediate response to an infiltrated IV as it helps prevent further harm to the patient. Stopping the infusion will prevent any more of the medication from entering the surrounding tissues, reducing the risk of tissue damage, infection, or other complications. Removing the catheter promptly is essential to prevent further infiltration and minimize the potential for adverse effects. The other options are incorrect in this context: A) Determining whether the infusion is a vesicant is important but not the immediate priority when an IV has infiltrated. C) Documenting the occurrence in the medical record is necessary but should be done after addressing the immediate issue. D) Elevating the extremity and monitoring the site can be done after removing the catheter but is not the initial step to take. In an educational context, understanding the correct response to an infiltrated IV is crucial for nurses caring for patients receiving IV medications, especially in high-risk situations like pregnancy. This knowledge ensures patient safety and prevents potential complications associated with IV therapy.