The nurse is caring for a client in active labor whose cervix is dilated 6 cm. The membranes rupture spontaneously, and the fetal monitor shows variable decelerations in the fetal heart rate. What action should the nurse take first?

Correct Answer: C

Rationale: In this scenario, the nurse's first action should be to change the maternal position (Option C). This is because variable decelerations in the fetal heart rate can indicate umbilical cord compression, and changing the maternal position can help relieve this compression by altering the baby's position in the uterus. This action is crucial in optimizing fetal oxygenation and reducing the risk of fetal distress. Assessing the amniotic fluid for meconium (Option A) may be important but is not the priority in this situation where fetal well-being is at risk. Performing a vaginal examination to assess for cord prolapse (Option B) could potentially worsen the cord compression if present, making it a dangerous choice as the first action. Lastly, preparing for an emergency cesarean section (Option D) is premature without exhausting less invasive interventions first. Educationally, this scenario highlights the importance of rapid and appropriate interventions in managing fetal distress during labor. It underscores the significance of understanding fetal monitoring patterns, knowing appropriate interventions, and prioritizing actions based on the situation's urgency to optimize maternal and fetal outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Abruptio placentae. Abruptio placentae is a serious complication where the placenta detaches from the uterine wall before delivery. The clinical manifestations align with the client's presentation of severe abdominal pain, bright red vaginal bleeding, high blood pressure, and fetal distress indicated by a decreased heart rate. Option A) Placenta previa is characterized by painless, bright red bleeding in the third trimester, usually without abdominal pain. This condition is unlikely in the presence of severe abdominal pain. Option C) Preterm labor typically presents with regular contractions leading to cervical changes and is not associated with severe abdominal pain and high blood pressure. Option D) Uterine rupture is a rare but life-threatening event that may present with sudden, severe abdominal pain, but it is not typically associated with vaginal bleeding and high blood pressure as seen in this case. Educationally, understanding the differences between these conditions is crucial for nurses working in maternity care to provide prompt and appropriate interventions, ensuring the best outcomes for both the mother and the baby. This case highlights the importance of recognizing and responding to signs of abruptio placentae promptly to prevent complications such as maternal hemorrhage and fetal distress.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to administer magnesium sulfate (Option A). This is because the client is presenting with signs and symptoms of severe preeclampsia, a serious pregnancy complication characterized by high blood pressure, headaches, visual disturbances, and epigastric pain. Magnesium sulfate is the drug of choice for preventing and treating seizures in preeclampsia and eclampsia, which are life-threatening conditions associated with this disorder. Assessing deep tendon reflexes (Option B) is important in the management of preeclampsia to monitor for signs of impending eclampsia, but it is not the first action to take in this acute situation. Notifying the healthcare provider (Option C) is important, but administering magnesium sulfate should take precedence due to the urgency of the client's symptoms. Administering hydralazine (Option D) is used to lower blood pressure in preeclampsia, but in this case, the client's symptoms indicate the need for immediate seizure prophylaxis with magnesium sulfate before addressing blood pressure control. In an educational context, understanding the priority actions in managing complications of pregnancy such as preeclampsia is crucial for nurses working in labor and delivery units. Timely and appropriate interventions can significantly impact maternal and fetal outcomes, making it essential for healthcare providers to be competent in recognizing and managing such conditions effectively.

Correct Answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take first is to prepare for an emergency cesarean section (Option C). This is because the client's presentation with severe abdominal pain, bright red vaginal bleeding, elevated blood pressure, and fetal distress indicates a potentially life-threatening situation such as placental abruption or other obstetric emergency, necessitating immediate delivery to save the lives of both the mother and the baby. Assessing the fetal heart rate pattern (Option A) is important, but in this critical situation, time is of the essence, and immediate action to deliver the baby is crucial. Performing a vaginal examination (Option B) may exacerbate the bleeding and is not the priority in this case. Administering oxygen via face mask (Option D) is important in improving oxygenation, but it does not address the primary issue of ensuring the safety and well-being of both the mother and the baby in this emergency situation. This scenario highlights the importance of recognizing obstetric emergencies, prioritizing actions based on the urgency of the situation, and being prepared to act swiftly to ensure the best possible outcomes for both the mother and the baby in a labor and delivery setting.

Correct Answer: B

Rationale: In this scenario, the nurse should suspect preeclampsia. Preeclampsia is characterized by high blood pressure (≥140/90 mm Hg) and proteinuria after 20 weeks of gestation in a previously normotensive woman. The presence of severe headache, visual disturbances, and epigastric pain further supports this diagnosis. If left untreated, preeclampsia can progress to eclampsia, which involves seizures. Gestational hypertension refers to elevated blood pressure without proteinuria after 20 weeks of gestation. Chronic hypertension predates pregnancy or occurs before 20 weeks of gestation. Educationally, understanding the nuances between these conditions is vital for nurses working in maternity care. Recognizing the signs and symptoms of preeclampsia is crucial for timely intervention to prevent severe complications for both the mother and the baby. Nurses must be able to differentiate between these hypertensive disorders to provide appropriate care and ensure optimal outcomes for pregnant individuals.