The nurse is caring for a client at 38 weeks' gestation with suspected placental abruption. What is the priority nursing action?

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: 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.

Correct Answer: A

Rationale: The correct answer is A) Verify signed informed consent. The priority nursing action before any invasive procedure like an amniocentesis is to ensure that the client has given informed consent. This is crucial as it upholds the principles of autonomy and beneficence, respecting the client's right to make decisions about their own healthcare. Without informed consent, the procedure cannot proceed ethically or legally. Option B) Administer prescribed analgesics is not the priority because while pain management is important for the client's comfort during the procedure, ensuring informed consent takes precedence. Option C) Encouraging the client to empty their bladder is important for the procedure but is not the priority over verifying informed consent. Option D) Positioning the client in a semi-Fowler's position is a procedural step for the amniocentesis but is not the priority before confirming informed consent. This scenario provides an important educational context about the ethical and legal responsibilities of healthcare providers in obtaining informed consent from clients before any medical procedure. It highlights the significance of respecting clients' autonomy and ensuring they have the necessary information to make informed decisions about their healthcare.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Check maternal blood pressure. When a client in labor receiving an epidural reports feeling lightheaded and nauseous, it could indicate hypotension, a common side effect of epidural anesthesia. Checking the maternal blood pressure is crucial to assess for hypotension, which can compromise both maternal and fetal well-being. Option A) Administer antiemetics as prescribed is incorrect because the priority is to address the potential hypotension first before treating the nausea. Option C) Increasing the oxytocin infusion rate is incorrect because the client is experiencing symptoms of hypotension, not related to the need for increased oxytocin. Option D) Encouraging the client to lie on her back is incorrect as this position can worsen hypotension. Educationally, understanding the potential side effects of epidural anesthesia, such as hypotension, is essential for nurses caring for laboring clients. Prompt assessment and intervention are crucial to ensure the safety of both the mother and the baby. Prioritizing interventions based on the client's condition and the potential risks involved is a fundamental aspect of maternal-newborn care.

Correct Answer: C

Rationale: In this scenario, the nurse's priority intervention should be option C: assess fetal heart rate and contraction pattern. This is the correct answer because when a client at 28 weeks' gestation reports regular uterine contractions, assessing the fetal heart rate and contraction pattern is crucial to determine the well-being of the fetus. Monitoring these parameters helps in evaluating fetal distress and the effectiveness of the contractions. It allows for timely intervention if there are signs of fetal compromise. Option A, administering tocolytic medication, is not the priority in this situation because before initiating tocolytic therapy, it is essential to assess the fetal status to determine if the contractions are causing any harm to the fetus. Performing a sterile vaginal examination (Option B) can introduce the risk of infection and should not be the immediate priority unless there are specific indications after assessing fetal well-being. Encouraging ambulation (Option D) may be helpful in some cases, but it is not the priority when the fetal well-being is in question. Educationally, this question highlights the importance of assessing fetal well-being in pregnant clients experiencing uterine contractions. It emphasizes critical thinking skills in prioritizing interventions based on the client's condition and the potential impact on fetal health. This rationale underscores the significance of accurate assessment and monitoring in maternal newborn care.