A woman in active labor experiences frequent and intense uterine contractions with minimal rest intervals, leading to maternal fatigue and decreased fetal oxygenation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?

Correct Answer: B

Rationale: Uterine hyperstimulation is a condition in which the uterus contracts too frequently or too intensely, leading to decreased blood flow and oxygenation to the placenta. This can result in maternal fatigue and decreased fetal oxygenation due to the lack of sufficient rest intervals between contractions. Uterine hyperstimulation can be caused by factors such as the use of synthetic oxytocin (Pitocin) to induce or augment labor, uterine abnormalities, or maternal conditions like pre-eclampsia. It is important for the nurse to assess for uterine hyperstimulation in a woman experiencing frequent and intense contractions to intervene promptly and prevent adverse outcomes for both the mother and the baby.

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.

Correct Answer: D

Rationale: When a postpartum client exhibits signs of postpartum psychosis such as hallucinations, delusions, and disorganized behavior, it is crucial to involve the healthcare provider immediately. Postpartum psychosis is a psychiatric emergency that requires prompt assessment and intervention by mental health professionals. The healthcare provider can determine the appropriate course of action, which may include hospitalization, medication management, and specialized psychiatric care. Delaying notification can lead to serious consequences for both the client and her infant, so timely intervention is essential in managing postpartum psychosis.