Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record lists the client's religion as Jehovah's Witness. What action should the nurse take?

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is option C: Clarify the client's wishes about receiving blood products. This is the most appropriate response because respecting the client's religious beliefs and autonomy is crucial in providing patient-centered care. Jehovah's Witnesses typically refuse blood transfusions due to religious beliefs, as they interpret certain Bible passages as prohibiting the ingestion of blood. Therefore, it is essential for the nurse to engage in a respectful and open conversation with the client to understand her preferences regarding medical interventions involving blood products. Option A, preparing to infuse multiple units of fresh frozen plasma, is incorrect because this action goes against the client's religious beliefs and autonomy. Option B, informing the client of the critical need for a blood transfusion, is not appropriate because it does not respect the client's religious beliefs and right to make informed decisions about her care. Option D, obtaining consent from the family to infuse packed red blood cells, is also incorrect as the decision should be based on the client's wishes, not the family's consent. Educationally, this scenario highlights the importance of cultural competence in nursing practice. Nurses must be aware of and respect the diverse cultural and religious beliefs of their clients to provide individualized and ethical care. It also underscores the significance of effective communication skills in discussing sensitive topics such as religious beliefs and treatment preferences with patients. By prioritizing patient autonomy and cultural sensitivity, nurses can uphold ethical standards and promote positive patient outcomes.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Heart rate and blood pressure. It is crucial to assess the client's vital signs first because the development of a perineal hematoma can be a sign of significant internal bleeding, which can lead to hypovolemic shock. Monitoring the heart rate and blood pressure will provide immediate information on the client's circulatory status and help the nurse determine the urgency of the situation. Option A (Abdominal contour and bowel sounds) is not the priority in this situation as the client's complaint of severe pain and pressure in the perineum, along with the presence of a perineal hematoma, indicates a more critical issue related to potential bleeding. Option B (Hemoglobin and hematocrit) is important for assessing blood loss but obtaining this information takes time. Vital signs provide immediate data on the client's condition and guide initial interventions. Option D (Urinary output and IV fluid intake) are important assessments but do not take precedence over monitoring vital signs in a client with signs of potential internal bleeding and hemodynamic instability. Educationally, this rationale highlights the critical thinking process in prioritizing assessments based on the client's presentation and potential complications. It underscores the importance of immediate action in situations where there is a risk of significant harm to the client.

Correct Answer: B

Rationale: The correct answer is B) Cries vigorously when stimulated. This is the best indication that the newborn is transitioning well to extrauterine life because crying helps the infant clear their airways, establish normal breathing patterns, and demonstrate neurological and respiratory function. Crying also indicates that the baby is responsive to external stimuli, which is a positive sign of their overall health and well-being. Option A, a heart rate of 220 beats/minute, is incorrect as it is too high for a newborn and could indicate distress or a medical issue. Option C, a positive Babinski reflex, is also incorrect as this reflex is normal in infants but doesn't necessarily indicate successful transition to extrauterine life. Option D, flexion of all four extremities, is a normal newborn reflex but alone does not provide as strong an indicator of successful transition as crying in response to stimulation. In an educational context, it is important for nurses and healthcare providers to understand the various signs and behaviors that indicate a newborn is transitioning well to life outside the womb. This knowledge helps them assess and monitor newborns effectively, ensuring they are adapting well to their new environment and are in good health.

Correct Answer: D

Rationale: In this scenario, the highest priority condition to assess for in the newborn with the given physical findings is hypoglycemia (Option D). Hypoglycemia is a critical concern in newborns, especially those who are small for gestational age like this newborn (4 pounds, 14 ounces). Low blood sugar levels can lead to serious complications such as brain injury or developmental delays. Given the infant's small size and potential limited glycogen stores, monitoring for hypoglycemia is crucial. The other options can be ruled out based on the provided physical findings: - Hyperthermia (Option A) is less likely as the infant's temperature is not mentioned and doesn't correlate with the other physical measurements. - Hyperbilirubinemia (Option B) typically presents with jaundice, which is not mentioned in the scenario. - Polycythemia (Option C) usually presents with signs like ruddy complexion, respiratory distress, and hypoglycemia, but in this case, the infant's physical findings do not strongly suggest polycythemia. Educationally, this question emphasizes the importance of recognizing the significance of physical assessment data in determining priority nursing actions for newborns, particularly in identifying and managing common newborn health issues promptly to prevent further complications. It highlights the critical nature of monitoring for hypoglycemia in at-risk newborns to ensure optimal outcomes.

Correct Answer: C

Rationale: The correct answer is C) Rapid increase in abdominal girth. In this scenario, the client is undergoing fertility treatment for anovulation and hyperprolactinemia. The medications being used can lead to ovarian hyperstimulation syndrome (OHSS), a serious complication characterized by fluid accumulation in the abdomen. A rapid increase in abdominal girth could be a sign of OHSS, which can be life-threatening if not addressed promptly. Option A) Episodes of headache and irritability are common side effects of fertility medications but are not typically considered urgent or life-threatening. Option B) Nausea and vomiting are also common side effects of fertility medications and are not typically indicative of a serious complication that requires immediate reporting. Option D) Persistent daytime fatigue is a non-specific symptom and is less likely to be associated with a critical condition like OHSS. Educationally, it is important for nurses to understand the potential side effects of fertility medications and the signs of complications such as OHSS. Prompt recognition and reporting of symptoms like a rapid increase in abdominal girth can help prevent serious consequences for the client. Nurses play a crucial role in educating clients about their fertility treatment, monitoring for side effects, and advocating for their well-being.