A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding but reports that she is not in pain. Ultrasound reveals a placenta previa. Which actions should the nurse implement?

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to implement is option D, which is to have the client transported to the hospital. Placenta previa is a serious condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding for both the mother and the baby. Immediate medical intervention is necessary to ensure the safety of the woman and her unborn child. Option A is incorrect because scheduling weekly prenatal appointments would not address the urgent need for immediate medical attention in the case of placenta previa. Option B, while addressing the woman's homelessness, is not the most critical action to take at this moment. Option C, obtaining a hemoglobin and hematocrit level, is important in general prenatal care but is not the priority when managing a case of placenta previa with active bleeding. From an educational perspective, this scenario highlights the importance of recognizing and responding to obstetric emergencies promptly. Nurses working with maternal and reproductive health clients need to be well-versed in identifying high-risk conditions like placenta previa and understanding the appropriate actions to take to ensure the safety and well-being of both the pregnant woman and her baby. Early recognition and intervention can significantly impact the outcomes in such critical situations.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is option C: Clarify the client's wishes about receiving blood products. This is the most appropriate response because respecting the client's religious beliefs and autonomy is crucial in providing patient-centered care. Jehovah's Witnesses typically refuse blood transfusions due to religious beliefs, as they interpret certain Bible passages as prohibiting the ingestion of blood. Therefore, it is essential for the nurse to engage in a respectful and open conversation with the client to understand her preferences regarding medical interventions involving blood products. Option A, preparing to infuse multiple units of fresh frozen plasma, is incorrect because this action goes against the client's religious beliefs and autonomy. Option B, informing the client of the critical need for a blood transfusion, is not appropriate because it does not respect the client's religious beliefs and right to make informed decisions about her care. Option D, obtaining consent from the family to infuse packed red blood cells, is also incorrect as the decision should be based on the client's wishes, not the family's consent. Educationally, this scenario highlights the importance of cultural competence in nursing practice. Nurses must be aware of and respect the diverse cultural and religious beliefs of their clients to provide individualized and ethical care. It also underscores the significance of effective communication skills in discussing sensitive topics such as religious beliefs and treatment preferences with patients. By prioritizing patient autonomy and cultural sensitivity, nurses can uphold ethical standards and promote positive patient outcomes.

Correct Answer: C

Rationale: The correct answer is C) An increased risk of aspiration can occur if general anesthesia is needed. During labor, there is a risk that the client may need general anesthesia for emergency procedures such as cesarean section. In such cases, having solid food in the stomach can lead to aspiration, where food particles or stomach contents enter the lungs. This can cause serious complications such as pneumonia, respiratory distress, and even death. Option A is incorrect because nausea from analgesics can be managed with antiemetic medications and does not necessarily require withholding solid food. Option B is incorrect because while autonomic nervous system stimulation during labor does decrease peristalsis (movement of food through the digestive system), this alone is not the primary reason for withholding solids. Option D is incorrect because gastric emptying time decreasing during labor is not the main concern when deciding to withhold solids. From an educational standpoint, it is important for nurses to understand the rationale behind withholding solids during labor to prevent potential complications and ensure the safety of maternal and reproductive health clients. Nurses play a crucial role in advocating for best practices and implementing evidence-based interventions to promote positive outcomes for laboring clients.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Heart rate and blood pressure. It is crucial to assess the client's vital signs first because the development of a perineal hematoma can be a sign of significant internal bleeding, which can lead to hypovolemic shock. Monitoring the heart rate and blood pressure will provide immediate information on the client's circulatory status and help the nurse determine the urgency of the situation. Option A (Abdominal contour and bowel sounds) is not the priority in this situation as the client's complaint of severe pain and pressure in the perineum, along with the presence of a perineal hematoma, indicates a more critical issue related to potential bleeding. Option B (Hemoglobin and hematocrit) is important for assessing blood loss but obtaining this information takes time. Vital signs provide immediate data on the client's condition and guide initial interventions. Option D (Urinary output and IV fluid intake) are important assessments but do not take precedence over monitoring vital signs in a client with signs of potential internal bleeding and hemodynamic instability. Educationally, this rationale highlights the critical thinking process in prioritizing assessments based on the client's presentation and potential complications. It underscores the importance of immediate action in situations where there is a risk of significant harm to the client.

Correct Answer: B

Rationale: The correct answer is B) Cries vigorously when stimulated. This is the best indication that the newborn is transitioning well to extrauterine life because crying helps the infant clear their airways, establish normal breathing patterns, and demonstrate neurological and respiratory function. Crying also indicates that the baby is responsive to external stimuli, which is a positive sign of their overall health and well-being. Option A, a heart rate of 220 beats/minute, is incorrect as it is too high for a newborn and could indicate distress or a medical issue. Option C, a positive Babinski reflex, is also incorrect as this reflex is normal in infants but doesn't necessarily indicate successful transition to extrauterine life. Option D, flexion of all four extremities, is a normal newborn reflex but alone does not provide as strong an indicator of successful transition as crying in response to stimulation. In an educational context, it is important for nurses and healthcare providers to understand the various signs and behaviors that indicate a newborn is transitioning well to life outside the womb. This knowledge helps them assess and monitor newborns effectively, ensuring they are adapting well to their new environment and are in good health.