A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the clients record indication that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the client cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement?

Correct Answer: D

Rationale: The correct action for the nurse to implement in this scenario is Option D: Instruct the client to use deep breathing during contractions. Deep breathing techniques can help the client manage pain and discomfort during labor without the need for additional pain medication. Option A: Discontinuing the Pitocin infusion is not necessary at this point as the client's cervical dilation is only 3 cm, and oxytocin is being used for labor augmentation. Option B: Administering additional Stadol IV push may lead to excessive sedation and respiratory depression, especially since the client was already medicated with Stadol and promethazine 30 minutes ago. Option C: Notifying the healthcare provider is not the priority in this situation since the client's condition does not warrant immediate medical intervention. Educationally, it is important for nurses to understand the appropriate pain management strategies during labor and to prioritize non-pharmacological interventions like deep breathing techniques before resorting to additional medications. Nurses need to assess the client's condition, consider the effects of previous medications, and provide holistic care that supports the client's comfort and well-being during labor.

Correct Answer: D

Rationale: The correct answer is D: If 10 kicks are not felt within 1 hr, drink orange juice and count for another hour. Rationale: This instruction is correct because the intake of glucose-rich orange juice can stimulate fetal movement due to the increase in blood sugar levels, making it easier to perceive fetal kicks. This step aims to ensure the well-being of the fetus by prompting movement if it is not initially detected. Option A is incorrect because exercising before counting kicks may lead to false perceptions of fetal movements due to increased maternal heart rate and movement, which can be confusing for the client. Option B is incorrect as counting movements for one hour before breakfast is not recommended. Fetal movement counts are typically advised to be done at a time when the fetus is most active, which may not necessarily be in the morning before breakfast. Option C is incorrect because avoiding caffeinated drinks for 24 hours before conducting the kick test is not necessary. Caffeine intake does not significantly impact fetal movements, and this instruction may add unnecessary restrictions for the client. Educational Context: Teaching pregnant clients how to perform kick counts is crucial for monitoring fetal well-being. Providing accurate instructions ensures that clients can effectively assess fetal movements and promptly seek medical attention if changes occur. Encouraging clients to follow evidence-based practices, such as drinking orange juice to stimulate fetal movements, empowers them to actively participate in monitoring their baby's health.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take is option A) Notify the healthcare provider of the finding. This is the most appropriate response because a fundal height measurement that exceeds expected gestational age could indicate issues such as polyhydramnios, macrosomia, or incorrect gestational age assessment. Notifying the healthcare provider promptly allows for further assessment, monitoring, and potential intervention to ensure the well-being of both the mother and the twins. Option B) Documenting the finding in the medical record is important but not sufficient as the next course of action. While documentation is essential for continuity of care, the priority in this situation is to address the potential concerns raised by the fundal height measurement. Option C) Scheduling the client for a biophysical profile may be premature at this point as it is typically done to assess fetal well-being in high-risk pregnancies. Further assessment and guidance from the healthcare provider are needed before proceeding to this step. Option D) Requesting another nurse to measure the fundus is unnecessary as the issue lies not in the accuracy of the measurement but in the clinical significance of the measurement exceeding the expected value. Educationally, this question highlights the importance of recognizing abnormal findings in maternal health assessments and the significance of timely communication with the healthcare team to ensure appropriate management and care for the pregnant client and her twins. It reinforces the critical role of the nurse in advocating for the health and well-being of their clients by promptly reporting and acting on abnormal findings.

Correct Answer: D

Rationale: In the case of a laboring client who is GBS+ (Group B streptococcus), the immediate treatment indicated is the administration of antibiotics (Option D). This is because Group B streptococcus is a bacterium that can be passed to the newborn during labor and delivery, potentially causing serious infections such as pneumonia, sepsis, or meningitis. Administering antibiotics to the mother during labor can significantly reduce the risk of transmission to the newborn. Option A, administration of Pitocin, is used to induce or augment labor and is not directly related to the treatment of GBS infection. Option B, artificial rupture of the membrane, can be a part of the labor process but does not address the specific concern of GBS infection. Option C, amnioinfusion for the baby, is a procedure used to address issues such as low amniotic fluid levels and is not the immediate treatment for GBS infection in a laboring client. In an educational context, understanding the importance of timely administration of antibiotics in GBS+ laboring clients is crucial for nurses caring for maternal and reproductive health clients. This knowledge ensures the safety of both the mother and the newborn by preventing potential complications associated with GBS infection. Nurses must be able to recognize the significance of this intervention to provide optimal care and promote positive maternal and neonatal outcomes.

Correct Answer: A

Rationale: In this scenario, the correct intervention is to position the radiant warmer over the crib (Option A) first. This is crucial because the preterm infant is displaying signs of respiratory distress and decreased muscle tone, indicating a need for immediate thermal support to prevent further complications. Placing the infant under the radiant warmer will help maintain the infant's body temperature, which is vital for stabilizing their condition and preventing hypothermia. Assessing the infant's blood glucose level (Option B) is important but not the priority in this situation where respiratory distress and hypothermia are primary concerns. Nipple feeding 1 ounce 1% glucose in water (Option C) can wait until the infant's condition is stabilized. Placing the infant in a side-lying position (Option D) is not the most appropriate intervention given the presented symptoms. In an educational context, understanding the priority of interventions in neonatal care is crucial for nurses working in maternal and reproductive health. This scenario highlights the importance of prioritizing interventions based on the infant's immediate needs to ensure optimal outcomes in neonatal care.