A pregnant client asks about the purpose of taking folic acid. What is the nurse's best response?

Correct Answer: B

Rationale: The correct answer is B) It helps prevent neural tube defects. Folic acid is a crucial nutrient during pregnancy as it plays a significant role in preventing neural tube defects such as spina bifida in the developing fetus. The neural tube develops into the baby's brain and spinal cord, so ensuring an adequate intake of folic acid is essential for the baby's healthy growth and development. Option A) It prevents gestational diabetes is incorrect because folic acid does not prevent gestational diabetes. Gestational diabetes is managed through proper diet, exercise, and sometimes medication under medical supervision. Option C) It supports fetal bone development is incorrect because while calcium and vitamin D are essential for fetal bone development, folic acid primarily focuses on preventing neural tube defects. Option D) It reduces the risk of preterm labor is incorrect as folic acid does not specifically reduce the risk of preterm labor. Preterm labor risk factors and prevention strategies involve various other factors unrelated to folic acid intake. Educationally, understanding the importance of folic acid in preventing neural tube defects is crucial for nurses caring for pregnant women. By providing accurate information to pregnant clients, nurses can help promote the best outcomes for both the mother and the developing fetus. This knowledge empowers nurses to educate and support pregnant clients in making informed decisions about their prenatal care.

Correct Answer: C

Rationale: In the context of a client in labor receiving epidural anesthesia, the priority nursing intervention is to frequently check maternal blood pressure (Option C). This is crucial because epidural anesthesia can cause hypotension, which can lead to decreased placental perfusion and compromise fetal oxygenation. Monitoring blood pressure allows for early detection of hypotension, enabling prompt intervention to maintain maternal and fetal well-being. Assessing for bladder distention (Option B) is important to prevent urinary retention, but it is not the priority when compared to monitoring blood pressure in this specific scenario. Monitoring maternal heart rate (Option A) is important, but blood pressure takes precedence due to its direct impact on perfusion. Encouraging frequent position changes (Option D) can help with labor progress and comfort but is not as critical as monitoring blood pressure in this situation. Educationally, this question highlights the importance of understanding the potential complications associated with epidural anesthesia during labor and the significance of prioritizing nursing interventions based on the client's condition and the potential impact on both maternal and fetal well-being. Nurses should be vigilant in monitoring vital signs and responding promptly to changes to ensure optimal outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Cholestasis of pregnancy. Severe itching without a rash in the third trimester should raise suspicion for cholestasis of pregnancy, a liver disorder that occurs during pregnancy and can lead to complications for both the mother and the fetus. Cholestasis of pregnancy is characterized by impaired bile flow, leading to a buildup of bile acids in the bloodstream, which can cause intense itching, typically on the palms and soles. Option B) Preeclampsia is a condition characterized by high blood pressure and signs of damage to another organ system, most commonly the liver and kidneys. While preeclampsia can present with symptoms such as headache, visual changes, and swelling, severe itching without a rash is not a typical symptom. Option C) Gestational diabetes is a condition where women without previously diagnosed diabetes develop high blood sugar levels during pregnancy. It is primarily associated with issues related to blood sugar control and typically does not present with severe itching without a rash. Option D) Fungal infection is unlikely in this case as severe itching without a rash is not a common presentation for a fungal infection, especially in the absence of other symptoms like redness, scaling, or discharge. Understanding these distinctions is crucial for nurses caring for pregnant clients, as prompt identification of conditions like cholestasis of pregnancy can lead to appropriate management and improved outcomes for both the mother and the baby. Nurses must be able to differentiate between various conditions that can arise during pregnancy to provide optimal care and support to their patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Contractions lasting 120 seconds. This finding would prompt the nurse to stop the oxytocin infusion because prolonged contractions can lead to uterine hyperstimulation, which can compromise fetal oxygenation and result in fetal distress. It is crucial to maintain an appropriate balance between uterine contractions for labor progress and ensuring fetal well-being during labor induction. Option A) Contractions every 2-3 minutes can be a normal response to oxytocin induction, but it alone does not indicate a need to stop the infusion. Option C) Baseline fetal heart rate of 140 beats/minute is within the normal range for a fetus at term and does not require stopping the infusion. Option D) Client reports mild back pain is a common discomfort during labor and is not a reason to discontinue the oxytocin infusion. Educationally, understanding the potential risks and complications of oxytocin administration during labor induction is essential for nurses caring for laboring women. It is crucial for nurses to recognize abnormal findings and take prompt actions to ensure the safety and well-being of both the mother and the fetus. Continuous monitoring and assessment skills are vital in obstetric care to provide safe and effective care during the labor and delivery process.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Fetal heart rate of 180 beats/minute. This finding requires immediate action because it indicates fetal distress, which is a serious concern during labor. A fetal heart rate of 180 beats/minute suggests fetal tachycardia, which can be a sign of insufficient oxygenation and potential hypoxia in the fetus. This situation requires prompt intervention to prevent adverse outcomes for the baby. Option A) Contractions lasting 90 seconds is not an immediate concern as long as there are no signs of fetal distress or hyperstimulation. Prolonged contractions can occur in some cases without causing harm. Option B) Contractions every 2-3 minutes can indicate hyperstimulation, but it may not be as urgent as fetal distress. Adjusting the oxytocin infusion rate can help manage this issue. Option D) Client reports mild nausea is not a critical finding in this context. Nausea can be a common side effect of oxytocin but does not pose an immediate threat to the fetus. Educationally, understanding the implications of fetal heart rate patterns and recognizing signs of fetal distress are crucial skills for nurses caring for laboring women. It is essential to prioritize interventions based on the urgency of the situation to ensure the best possible outcomes for both mother and baby.