A primigravida at 39 weeks gestation presents to the labor and delivery unit with contractions every 5 minutes, lasting 45 seconds each. On examination, her cervix is dilated to 3 cm. What is the appropriate nursing intervention?

Correct Answer: A

Rationale: The appropriate nursing intervention in this case is to encourage the mother to walk to facilitate labor progression. The patient is in early labor with contractions every 5 minutes, lasting 45 seconds each, and her cervix is dilated to 3 cm. Encouraging the mother to walk can help gravity assist the descent of the baby and promote cervical dilation. Walking can also help alleviate some discomfort and encourage labor progression. It is important to promote natural, non-invasive methods to support the progress of labor before considering medical interventions such as oxytocin or cesarean section. Relaxation techniques can also be beneficial in managing pain during labor.

Correct Answer: C

Rationale: An amniotic fluid embolism is a rare and life-threatening complication during labor and delivery. It occurs when amniotic fluid or fetal cells enter the maternal circulation, triggering a rapid immune response that can lead to cardiovascular collapse and respiratory failure. The priority nursing intervention for a woman in active labor diagnosed with an amniotic fluid embolism is to initiate cardiopulmonary resuscitation (CPR) to support her vital functions and circulation. Providing immediate CPR can help sustain her until further medical interventions can be implemented. Administering oxygen and preparing for a cesarean section may be necessary but should occur after CPR is initiated to stabilize the woman's condition. Inserting an indwelling urinary catheter is not the priority in this emergency situation, as maintaining adequate cardiac and respiratory function takes precedence.

Correct Answer: C

Rationale: Uterine rupture is a severe obstetric complication that requires prompt and decisive management to prevent adverse outcomes for both the mother and the baby. In cases of uterine rupture leading to fetal distress and maternal hemorrhage, performing an emergency cesarean section is crucial. This intervention allows for rapid delivery of the baby, relieving the distress on the fetus and enabling immediate access to manage the maternal hemorrhage. By performing a timely cesarean section, healthcare providers can expedite the delivery process and effectively address both the fetal and maternal complications associated with uterine rupture. This intervention is essential in saving lives and reducing the risk of further complications in such a critical obstetric emergency.

Correct Answer: B

Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition characterized by frequent and intense uterine contractions with minimal rest intervals. This can lead to maternal fatigue and decreased fetal oxygenation due to the insufficient time for the uterus to relax and refill with oxygenated blood between contractions. Uterine hyperstimulation can be caused by various factors such as excessive use of uterotonics (oxytocin or prostaglandins), improper labor induction techniques, or maternal conditions like previous uterine surgery. It is essential for the nurse to assess for signs of uterine hyperstimulation and take appropriate interventions to prevent potential complications for both the mother and the baby.

Correct Answer: A

Rationale: The sensation of feeling "heavy" in the perineal area postpartum is a common concern due to the stretching and potential trauma to the perineal muscles during childbirth. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help alleviate this sensation of heaviness. By encouraging the client to perform Kegel exercises regularly, the nurse is promoting the restoration and strengthening of the perineal muscles, ultimately helping the client feel more comfortable and supported in that area. This education empowers the client to take an active role in their own recovery and promotes optimal healing postpartum.