A woman in active labor requests hydrotherapy for pain relief. What is the nurse's priority action before initiating hydrotherapy?

Correct Answer: C

Rationale: Before initiating hydrotherapy for pain relief during labor, the nurse's priority action should be to assess the maternal and fetal conditions to determine if the mother is eligible for this form of pain management. It is essential to ensure that hydrotherapy is safe and appropriate for the specific situation. Assessing the maternal condition includes evaluating factors such as the stage of labor, maternal and fetal well-being, and any medical conditions that could impact the use of hydrotherapy. This assessment helps to identify any contraindications or risks that may affect the mother and baby during hydrotherapy. By conducting a thorough assessment, the nurse can make an informed decision about whether hydrotherapy is suitable for the woman in labor.

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: 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: 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.