An obviously pregnant woman walks into the hospital's emergency department entrance shouting. 'Help me! Help me! My baby is coming! I'm so afraid!' The nurse determines if delivery is indeed imminent, what action is most important for the nurse to take?

Correct Answer: D

Rationale: In this scenario, the most important action for the nurse to take is to provide clear concise instructions in a calm, deliberate manner (Option D). This is the correct answer because effective communication is crucial in emergency situations. By remaining calm and providing clear instructions, the nurse can help reassure the pregnant woman, maintain a sense of control, and guide her through the delivery process until medical help arrives. Option A, determining the gestational age of the fetus, is not the most immediate concern in this urgent situation. Assessing the amount and color of the amniotic fluid (Option B) is also important but not as critical as ensuring clear communication with the patient. Similarly, obtaining IV access and starting IV fluids (Option C) can be important but should not take precedence over providing immediate support and instructions to the woman in labor. In an educational context, this question highlights the significance of effective communication and quick decision-making in emergency obstetric care. Nurses need to be prepared to handle unexpected situations with composure and clarity to ensure the safety and well-being of both the mother and the baby. Training in emergency obstetric care equips healthcare providers with the skills needed to respond promptly and appropriately in high-stress situations like imminent deliveries.

Correct Answer: C

Rationale: The correct answer is C) A fluctuation in hormones in the early postpartum period can cause mood changes. This response is most important for the nurse to provide the father because it educates him about the common phenomenon of postpartum mood changes due to hormonal fluctuations in new mothers. By understanding this, the father can be more empathetic and supportive towards his wife during this challenging time. Option A is incorrect because waiting for two weeks for a situation to improve could be detrimental to the mother's mental health if she is experiencing postpartum depression or anxiety. Option B is irrelevant to the situation described and does not address the mother's emotional well-being. Option D is incorrect as it suggests giving supplemental bottle feedings, which may not be necessary and could interfere with successful breastfeeding. In an educational context, it is crucial for healthcare providers to educate families about the physical and emotional changes that new mothers may experience postpartum. By understanding these changes, families can provide better support and seek appropriate help if needed to ensure the well-being of both the mother and the newborn.

Correct Answer: D

Rationale: The correct action for the nurse to implement in this scenario is Option D: Instruct the client to use deep breathing during contractions. Deep breathing techniques can help the client manage pain and discomfort during labor without the need for additional pain medication. Option A: Discontinuing the Pitocin infusion is not necessary at this point as the client's cervical dilation is only 3 cm, and oxytocin is being used for labor augmentation. Option B: Administering additional Stadol IV push may lead to excessive sedation and respiratory depression, especially since the client was already medicated with Stadol and promethazine 30 minutes ago. Option C: Notifying the healthcare provider is not the priority in this situation since the client's condition does not warrant immediate medical intervention. Educationally, it is important for nurses to understand the appropriate pain management strategies during labor and to prioritize non-pharmacological interventions like deep breathing techniques before resorting to additional medications. Nurses need to assess the client's condition, consider the effects of previous medications, and provide holistic care that supports the client's comfort and well-being during labor.

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to implement is option B: Obtain signed consent from the mother for administration of the hepatitis B vaccine. This is the right choice because obtaining informed consent is a fundamental ethical and legal requirement before administering any vaccine, ensuring that the parent is aware of the benefits and risks associated with the vaccination. Option A is incorrect because administering rotavirus vaccine during diarrhea can be contraindicated due to the risk of exacerbating dehydration. Option C is also incorrect as DTaP is usually not given to newborns but rather at 2, 4, and 6 months of age. Option D is incorrect because the decision to immunize should not be left solely to the parent's discretion without proper education and guidance from healthcare providers. In an educational context, understanding the importance of informed consent in healthcare is crucial for nurses and other healthcare providers. It ensures that patients and their families actively participate in the decision-making process regarding their health and treatment, promoting autonomy and ethical care practices. Nurses play a key role in educating parents about the benefits of immunizations, addressing concerns, and obtaining consent to ensure the well-being of both the child and the community.

Correct Answer: D

Rationale: The correct answer is D: If 10 kicks are not felt within 1 hr, drink orange juice and count for another hour. Rationale: This instruction is correct because the intake of glucose-rich orange juice can stimulate fetal movement due to the increase in blood sugar levels, making it easier to perceive fetal kicks. This step aims to ensure the well-being of the fetus by prompting movement if it is not initially detected. Option A is incorrect because exercising before counting kicks may lead to false perceptions of fetal movements due to increased maternal heart rate and movement, which can be confusing for the client. Option B is incorrect as counting movements for one hour before breakfast is not recommended. Fetal movement counts are typically advised to be done at a time when the fetus is most active, which may not necessarily be in the morning before breakfast. Option C is incorrect because avoiding caffeinated drinks for 24 hours before conducting the kick test is not necessary. Caffeine intake does not significantly impact fetal movements, and this instruction may add unnecessary restrictions for the client. Educational Context: Teaching pregnant clients how to perform kick counts is crucial for monitoring fetal well-being. Providing accurate instructions ensures that clients can effectively assess fetal movements and promptly seek medical attention if changes occur. Encouraging clients to follow evidence-based practices, such as drinking orange juice to stimulate fetal movements, empowers them to actively participate in monitoring their baby's health.