A woman admitted to the labor and delivery unit in bruising over the shoulder area and an abrasion on early labor gives the following obstetric history. She the scalp. What are these markings most likely the gave birth to her daughter at 38 weeks and her twin result of?

Correct Answer: B

Rationale: The bruising over the shoulder area and the abrasion on the scalp of a woman admitted to the labor and delivery unit during early labor are most likely the result of abuse by a caregiver. These types of injuries can be indicative of physical abuse, especially in vulnerable populations such as pregnant women. It is important for healthcare providers to be alert for signs of abuse and to report any suspicions or evidence to ensure the safety of the mother and the baby. In cases like this, a thorough assessment and appropriate intervention are necessary to protect the well-being of the mother and the unborn child.

Correct Answer: B

Rationale: Calcium gluconate is indeed the antidote for magnesium sulfate toxicity. In cases where a pregnant client is receiving magnesium sulfate for conditions like preeclampsia, it is important to have calcium gluconate readily available in case of magnesium toxicity. This is a crucial intervention to prevent any adverse effects on both the mother and the baby. So, the nurse should ensure that calcium gluconate is available and be prepared to administer it if needed.

Correct Answer: A

Rationale: The most appropriate action for the nurse to take in this situation is to discontinue the medication infusion. The client is showing signs of magnesium sulfate toxicity, which can include respiratory depression (low respiratory rate) and absent deep-tendon reflexes. These are early signs of magnesium toxicity, and prompt action is needed to prevent further complications. Discontinuing the medication infusion will help reduce the risk of magnesium toxicity worsening. The other options are not appropriate in this situation as they do not address the immediate concern of magnesium toxicity.

Correct Answer: B

Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.

Correct Answer: C

Rationale: The correct instruction for the nurse to include in the discharge plan is to encourage frequent feeding to increase intake. Fiber-optic blankets for treating physiologic jaundice work by promoting the breakdown of bilirubin in the skin through phototherapy. Encouraging frequent feeding helps increase the infant's intake, leading to more frequent bowel movements which aids in the elimination of excess bilirubin from the body. This, in turn, helps in resolving physiologic jaundice more quickly. Covering the infant's eyes during treatment may be necessary to protect them from the bright light, but it is not directly related to the effectiveness of the treatment. Reducing the number of formula feedings could decrease the baby's intake, potentially leading to more concentrated levels of bilirubin. Expecting constipation until jaundice clears is not a typical consequence of using a fiber-optic blanket for jaundice treatment.