A woman in active labor is experiencing persistent occiput posterior position despite position changes. What nursing intervention is most appropriate to facilitate fetal rotation?

Correct Answer: B

Rationale: The most appropriate nursing intervention to facilitate fetal rotation in a woman experiencing persistent occiput posterior position is to assist the mother into a hands-and-knees position. This position can help encourage the baby to rotate into the optimal occiput anterior position for delivery. By being on her hands and knees, gravity can assist in aiding the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially reduce discomfort during labor. Additionally, hands-and-knees position can help open up the pelvis and create more space for the baby to turn. It is a non-invasive and generally well-tolerated intervention to promote fetal rotation in labor.

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.

Correct Answer: A

Rationale: The priority nursing intervention in this situation is to first assess the client for signs of urinary retention or bladder distention. Difficulty in emptying the bladder completely and experiencing urinary frequency can be indications of urinary retention, which can lead to bladder distention and possible complications such as urinary tract infection. By assessing the client, the nurse can determine the cause of the issue and implement appropriate interventions. It is crucial to address potential complications promptly to promote the client's health and well-being postpartum. Once the assessment is completed, further interventions such as recommending appropriate measures, like warm compresses or pelvic floor exercises, can be considered based on the assessment findings.