A woman in active labor presents with prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?

Correct Answer: A

Rationale: Pelvic floor dysfunction can contribute to a prolonged second stage of labor by impairing the ability of the woman to effectively push during contractions. This can result in inefficient pushing efforts and slow fetal descent. The nurse should assess for signs and symptoms of pelvic floor dysfunction, such as difficulty controlling bowel movements or urine leakage, as addressing this issue may help improve the progress of labor. Maternal fatigue, fetal macrosomia (larger than average baby size), and uterine hyperstimulation are other factors that can impact labor but are less likely to specifically contribute to ineffective pushing efforts and slow fetal descent in the second stage of labor.

Correct Answer: B

Rationale: Educating the client about the "baby blues" phenomenon should be prioritized as it is a common occurrence that happens to many women after giving birth. The "baby blues" refer to feelings of sadness, irritability, and tearfulness that many new mothers experience due to hormonal changes and the stress of adjusting to motherhood. By understanding that these feelings are a normal part of the postpartum period and that they usually resolve on their own within a few weeks, the client may feel reassured and supported. Providing information and support can help the client cope with these emotions and reduce any anxiety or distress they may be feeling. If the client's emotional state does not improve or becomes more severe, further intervention such as referring to a mental health professional may be necessary. But initially, education and reassurance about the "baby blues" can be an effective nursing intervention to address the client's emotional well-being.

Correct Answer: A

Rationale: Educating the client about the importance of balanced nutrition and frequent monitoring of blood glucose levels should be prioritized to address the client's concerns about managing blood sugar levels while breastfeeding. This intervention helps empower the client to make informed choices about her diet and monitor her blood sugar levels effectively. By focusing on balanced nutrition and regular blood glucose monitoring, the client can better manage her blood sugar levels during the postpartum period and while breastfeeding, reducing the risk of complications associated with gestational diabetes. It also promotes overall health and well-being for both the mother and the baby.

Correct Answer: A

Rationale: Providing emotional support and empathy for the client's experience should be prioritized to address concerns of a postpartum client who experienced a traumatic birth. Emotional support can help the client feel validated and heard, which can be instrumental in starting the healing process. By acknowledging the client's emotions and experiences, the nurse can establish trust and create a safe space for the client to express their feelings. This can also help in building a therapeutic relationship that can positively impact the client's emotional well-being. Providing a supportive environment is essential for addressing breastfeeding difficulties and emotional distress in this situation.

Correct Answer: C

Rationale: The sudden onset of shortness of breath, chest pain, and cyanosis in a postpartum client could be indicative of a pulmonary embolism, a potentially life-threatening condition. Therefore, it is crucial to notify the healthcare provider immediately for further assessment and management. Prompt intervention is essential in this situation to prevent any potential complications and ensure the client receives appropriate care as soon as possible. Placing the client in a semi-Fowler's position or administering supplemental oxygen therapy may provide temporary relief, but the priority is to seek immediate medical attention. Consulting with the healthcare provider ensures that the client receives the necessary interventions promptly.