The nurse is caring for a client at 38 weeks' gestation reporting decreased fetal movement. What is the priority action?

Correct Answer: A

Rationale: In this scenario, the priority action for the nurse caring for a client at 38 weeks' gestation reporting decreased fetal movement is to perform a nonstress test (NST). This test monitors the fetal heart rate in response to fetal movement, helping assess fetal well-being quickly and non-invasively. Performing an NST is crucial because decreased fetal movement could indicate fetal distress or compromise, which requires immediate evaluation to prevent adverse outcomes. The NST provides real-time information on fetal well-being, guiding further interventions or decisions. Instructing the client to drink orange juice (Option B) is not the priority in this situation as it may temporarily increase fetal activity but does not provide a comprehensive assessment of fetal well-being like an NST does. Scheduling an ultrasound (Option C) is important for assessing fetal anatomy and growth but may not provide immediate information on fetal well-being compared to an NST. Notifying the healthcare provider immediately (Option D) is important but performing an NST first allows the nurse to provide timely data to the provider for informed decision-making. Educationally, understanding the importance of prompt assessment and intervention in cases of decreased fetal movement is crucial for nurses caring for pregnant clients to ensure optimal outcomes for both the mother and the baby.

Correct Answer: B

Rationale: In this scenario, option B, "It is normal to have heavy bleeding for two weeks," indicates the need for further teaching. Postpartum bleeding, known as lochia, typically lasts for about 4-6 weeks, with the flow gradually decreasing over time. Heavy bleeding persisting for two weeks could signal a potential issue, such as retained placental tissue or infection, requiring medical attention. Option A, "I will call my doctor if I have a fever," is correct as fever can be a sign of infection postpartum, which needs prompt evaluation and treatment. Option C, "I will avoid lifting heavy objects," is also correct as heavy lifting can strain the healing tissues post-delivery. Option D, "Breast tenderness is common when my milk comes in," is correct as breast tenderness is a common occurrence during lactation due to engorgement and milk production. Educationally, it is essential for nurses to provide accurate information about postpartum care to ensure the well-being of both the mother and the newborn. Recognizing signs of complications early is crucial for timely intervention and optimal recovery. Empowering clients with correct knowledge enhances their ability to make informed decisions and promotes positive health outcomes.

Correct Answer: A

Rationale: In the scenario of a client at 38 weeks' gestation with suspected placental abruption, the priority nursing action is to assess maternal vital signs and fetal heart rate (Option A). This is crucial in determining the immediate status of both the mother and the baby. Placental abruption can lead to serious complications, including maternal hemorrhage and fetal distress, necessitating close monitoring of vital signs and fetal well-being. Preparing the client for immediate cesarean delivery (Option B) may be necessary depending on the severity of the abruption, but it should not be the immediate priority without assessing the current status of the mother and baby first. Administering oxygen (Option C) is important in cases of suspected placental abruption, but assessing the vital signs and fetal heart rate takes precedence. Inserting an indwelling urinary catheter (Option D) is not the priority in this situation and does not address the immediate threat to the mother and baby's health. In an educational context, understanding the hierarchy of nursing actions in emergencies like placental abruption is vital for providing safe and effective care. Prioritizing assessments allows for timely interventions and can improve outcomes for both the mother and the baby. Nurses need to be able to quickly identify the most critical actions to take in high-stress situations to provide optimal care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Assess for cervical changes and fetal heart rate. The priority action for a client experiencing regular uterine contractions at 32 weeks' gestation is to assess for cervical changes and fetal heart rate to determine if the client is in preterm labor. This assessment is crucial for evaluating the status of the pregnancy and determining the appropriate course of action. Option A) Administer tocolytic medication as prescribed is incorrect because administering tocolytic medication should only be done after assessing for cervical changes and confirming preterm labor. Tocolytic medication is used to inhibit uterine contractions and delay preterm birth. Option B) Performing a sterile vaginal examination is not the priority in this situation as it can potentially introduce infection and is not necessary until the assessment of cervical changes and fetal heart rate has been completed. Option D) Encouraging ambulation to relieve discomfort is not the priority when there is a concern for preterm labor. While ambulation can sometimes help alleviate discomfort, it is not the appropriate action when assessing for preterm labor. Educationally, this scenario highlights the importance of prioritizing assessments in obstetric nursing. Understanding the sequence of actions in response to signs of preterm labor is critical in providing safe and effective care to pregnant clients. Early identification and timely intervention can significantly impact outcomes for both the mother and the baby.

Correct Answer: B

Rationale: In the context of pharmacology and the care of a client in the second stage of labor, the correct assessment indicating that birth is imminent is option B: "Fetal head is crowning." This is because crowning, which refers to the visible part of the baby's head at the vaginal opening, typically occurs just before birth is about to happen. This visual cue signifies that the baby is descending through the birth canal and delivery is imminent. Option A, "Cervix is dilated to 8 cm," is an important assessment indicating progress in labor but does not specifically indicate that birth is imminent. It shows the stage of dilation but not necessarily the exact timing of birth. Option C, "Contractions every 3-5 minutes," is a common pattern seen in the active phase of labor but does not provide a definitive indication that birth is about to happen in the immediate term. Option D, "Client reports back pain," is a vague symptom that can occur at various stages of labor and does not specifically signal that birth is imminent. In an educational context, understanding the nuances of labor assessments is crucial for nurses to provide appropriate care and support during childbirth. Recognizing the signs of imminent birth, such as crowning, helps nurses prepare for the delivery process and provide timely interventions if necessary. This knowledge is essential for ensuring the safety and well-being of both the mother and the newborn.