A woman in active labor demonstrates signs of cephalopelvic disproportion (CPD), with the fetal head failing to descend despite strong contractions. What nursing action should be prioritized to address this abnormal labor presentation?

Correct Answer: D

Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.

Correct Answer: B

Rationale: Postural hypotension, also known as orthostatic hypotension, is a common issue postpartum and can cause lightheadedness when standing up. When a postpartum client expresses concern about feeling lightheaded, assessing for postural hypotension should be a priority. This assessment involves measuring the client's blood pressure while lying down, sitting, and standing to identify any significant drops in blood pressure upon changing positions. Identifying postural hypotension early allows for appropriate interventions to prevent potential falls and address the client's symptoms. Checking blood pressure, evaluating hemoglobin levels, and monitoring for signs of hemorrhage are also important assessments but may not directly address the specific issue of feeling lightheaded when standing up in this scenario.

Correct Answer: D

Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.

Correct Answer: A

Rationale: Demonstrating tandem breastfeeding positions and techniques should be prioritized as the nursing intervention to address the client's concerns about breastfeeding both infants simultaneously. Tandem breastfeeding involves nursing twins at the same time and can help enhance milk production, promote bonding with both infants, and save time for the mother. By showing the client the proper positions and techniques for tandem breastfeeding, the nurse can empower the client with the knowledge and skills needed to successfully breastfeed both infants together. This intervention can ultimately support the client in feeling more confident and competent in managing the challenges of breastfeeding twins.

Correct Answer: D

Rationale: The prioritized nursing intervention in this situation should be assessing for the risk of harm to self or infant. It is crucial to ensure the safety of the postpartum client and her infant as depression can increase the risk of self-harm or harm to the newborn. By assessing for any potential risks, the nurse can take appropriate actions to prevent any harm and ensure the well-being of both the client and the infant. Once the assessment is completed, further interventions like encouraging participation in support groups, referring to a mental health professional, or administering medications can be considered based on the assessment findings.