The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

Correct Answer: C

Rationale: In this scenario, the correct intervention is to monitor bleeding from IV sites (Option C). This choice is appropriate because the client is experiencing dark red vaginal bleeding, which indicates a potential hemorrhage. Monitoring for bleeding from IV sites is crucial as it can help identify if the bleeding is generalized or localized, providing essential information for the healthcare team to manage the situation effectively. Assessing for cervical changes q1h (Option B) is not the priority in this case as the client's vaginal bleeding and uterine tone suggest a more urgent issue related to potential hemorrhage. Inserting an internal fetal monitor (Option A) or performing Leopold's maneuvers (Option D) are also not indicated at this time as the primary concern is addressing the maternal health status. From an educational perspective, this question highlights the importance of prioritizing interventions based on the client's immediate needs. Understanding the significance of assessing and managing maternal hemorrhage is critical for nurses working in labor and delivery units to ensure the safety and well-being of both the mother and the baby. By mastering these principles, nurses can provide high-quality care and potentially save lives in emergency situations.

Correct Answer: A

Rationale: In the context of client teaching for gravid clients, the factor with the greatest influence on successful teaching is the client's readiness to learn (Option A). This is because a client's willingness and ability to engage with the information being presented significantly impact the effectiveness of the teaching process. When a client is motivated and open to learning, they are more likely to retain and apply the information provided by the maternity nurse. Clients who are ready to learn are more likely to ask questions, participate actively in discussions, and follow through with recommended practices, leading to better maternal and reproductive health outcomes. Regarding the other options: - Option B (The client's educational background) is less influential because regardless of a client's educational level, their readiness to learn can still vary. Education does not always correlate with a person's receptiveness to new information. - Option C (The order in which the information is presented) is important but not as critical as the client's readiness. While presentation order can impact comprehension, if the client is not receptive, the sequencing of information becomes less effective. - Option D (The extent to which the pregnancy was planned) may have some impact on the client's mindset and readiness to engage in learning, but it is not as directly related to the teaching process as the client's actual readiness to learn. In educational context, understanding and assessing the client's readiness to learn is fundamental for a maternity nurse to tailor their teaching strategies effectively. By recognizing and responding to the client's readiness, nurses can optimize the teaching process, promote client engagement, and ultimately enhance the client's maternal and reproductive health outcomes.

Correct Answer: B

Rationale: The most common neonatal birth trauma due to vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fracture clavicle should be suspected is an infant has limited use of the affected arm malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.

Correct Answer: D

Rationale: The most important instruction for a woman who had a miscarriage 6 months ago and is now pregnant is to take prescribed multivitamin and mineral supplements (Option D). This instruction is crucial because proper nutrition, including essential vitamins and minerals, is vital for supporting a healthy pregnancy and reducing the risk of complications. Elevating lower legs while resting (Option A) is not directly related to the specific needs of a pregnant woman who previously experienced a miscarriage. Increasing caloric intake by 200 to 300 calories per day (Option B) can be important during pregnancy, but it is not the most critical instruction in this scenario. Increasing water intake to 8 full glasses per day (Option C) is generally good advice for overall health but is not as directly essential as ensuring proper vitamin and mineral intake during pregnancy. In an educational context, it is important for nurses to understand the specific needs of women who have experienced miscarriages and are now pregnant. Providing targeted and evidence-based instructions, such as the importance of taking prescribed multivitamin and mineral supplements, is crucial for promoting the health and well-being of both the mother and the developing fetus. Nurses play a key role in educating and supporting women through their reproductive health journey, and ensuring they have the necessary information to optimize their outcomes.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Central cyanosis when crying. This finding indicates a potential issue with oxygenation, which is crucial for infant health. Central cyanosis suggests inadequate oxygenation of the central circulation and can be a sign of serious conditions such as respiratory distress or congenital heart defects. Option A, a blood glucose level of 45 mg/dl, though low, is not the most critical finding to report in this case as it is within the range of expected blood glucose levels in newborns. Option B, a blood pressure of 82/45 mmHg, is low but not as concerning as central cyanosis. Blood pressure values can vary widely in newborns, and this value alone may not be alarming. Option C, a non-bulging anterior fontanel, is actually a normal finding in a newborn and does not indicate an immediate concern. Educationally, it is important for nursery nurses to understand the significance of various assessment findings in newborns to provide safe and effective care. Recognizing and prioritizing abnormal findings, such as central cyanosis in this case, is crucial for timely intervention and ensuring the well-being of maternal and reproductive health clients.