The nurse is caring for a client in active labor who is receiving oxytocin (Pitocin) to augment labor. The nurse notes late decelerations in the fetal heart rate. What action should the nurse take first?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to stop the oxytocin infusion (Option A). Late decelerations in the fetal heart rate indicate uteroplacental insufficiency, which can be exacerbated by the use of oxytocin. Stopping the infusion allows for the assessment of the fetal well-being and helps to prevent further compromise. Turning the client to a lateral position (Option B) can help improve fetal oxygenation by relieving pressure on the vena cava, but in the presence of late decelerations, stopping the oxytocin is the priority. Administering oxygen via a face mask (Option C) can be beneficial in cases of fetal distress, but addressing the underlying cause, in this case, the oxytocin infusion, is crucial. Notifying the healthcare provider (Option D) is important, but immediate action to address the fetal distress should take precedence to ensure the safety and well-being of both the mother and the baby. In an educational context, understanding the significance of fetal heart rate patterns and the appropriate interventions is crucial for nurses caring for laboring clients. This knowledge ensures timely and effective responses to changes in fetal status, promoting optimal outcomes for both mother and baby.

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.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to assess the client's blood pressure (Option A). This is crucial because the client's symptoms of feeling dizzy and lightheaded could indicate hypotension, which can be a serious concern during labor. Monitoring the blood pressure will provide vital information about the client's perfusion status and guide further interventions. Placing the client in a left lateral position (Option B) is generally beneficial to optimize fetal oxygenation but may not address the immediate concern of the client's dizziness. Administering oxygen via face mask (Option C) is important in cases of hypoxia, but assessing blood pressure takes precedence in this situation to identify the underlying cause of the client's symptoms. Notifying the healthcare provider (Option D) can be done after the initial assessment is completed and necessary interventions are initiated. Educationally, understanding the prioritization of nursing actions based on the client's condition is essential for providing safe and effective care. This question highlights the importance of quick and accurate assessment in responding to maternal and fetal well-being during labor and delivery, emphasizing the significance of timely interventions to address potential complications.