The nurse is caring for a client in active labor with late decelerations on the monitor. What is the priority nursing intervention?

Correct Answer: A

Rationale: In the scenario presented, the priority nursing intervention when caring for a client in active labor with late decelerations on the monitor is to reposition the client to her side (Option A). This intervention is crucial as it helps improve placental perfusion by alleviating pressure on the vena cava and aorta, thus enhancing fetal oxygenation. Repositioning the client is effective in addressing the underlying cause of late decelerations, which is often due to compression of the umbilical cord or reduced blood flow to the placenta during contractions. By changing the client's position, the nurse can potentially improve blood flow to the placenta, thereby promoting better fetal oxygenation and reducing the risk of fetal distress. Administering IV fluids (Option B) may be important in certain situations to maintain hydration and support maternal blood pressure, but it is not the priority when late decelerations are observed. Applying oxygen via a face mask (Option C) can be beneficial in cases of fetal distress, but repositioning the client takes precedence in this scenario. Notifying the healthcare provider (Option D) is important, but it is not the immediate priority when interventions that can directly impact fetal oxygenation, like repositioning, are available to the nurse. In maternal newborn care, quick and appropriate actions can significantly influence maternal and fetal outcomes, making understanding and implementing priority interventions crucial for nurses in these situations.

Correct Answer: B

Rationale: In the context of caring for a client with severe preeclampsia, magnesium sulfate is often used to prevent seizures. Therefore, monitoring for signs of magnesium sulfate toxicity is crucial. Option B, a respiratory rate of 10 breaths per minute, indicates magnesium sulfate toxicity as it is a central nervous system depressant and can lead to respiratory depression at toxic levels. This finding is a critical indicator of impending magnesium sulfate toxicity and requires immediate intervention. Option A, increased deep tendon reflexes, is actually a sign of magnesium deficiency rather than toxicity. Magnesium sulfate usually dampens reflexes, so an increase would not be indicative of toxicity. Option C, urine output of 50 mL/hour, is generally considered a normal urine output and is not specific to magnesium sulfate toxicity. Option D, a blood pressure of 160/110 mmHg, is a common finding in preeclampsia but is not a specific indicator of magnesium sulfate toxicity. Educationally, understanding the signs of magnesium sulfate toxicity is essential for nurses caring for pregnant clients with preeclampsia. It highlights the importance of close monitoring and prompt recognition of adverse effects to ensure the safety of both the mother and the baby.

Correct Answer: C

Rationale: In maternal newborn care, educating clients about kick counts is crucial for monitoring fetal well-being. The most appropriate instruction is option C: Count 10 fetal movements over 2 hours. This is the correct answer because it aligns with current guidelines recommending daily kick counts to assess fetal activity, with the expectation of feeling at least 10 movements within a 2-hour period. This frequency allows for regular monitoring of fetal health and prompt identification of any potential issues. Option A is incorrect as performing kick counts only once a week may not provide timely information about changes in fetal activity that could indicate distress. Option B is also inaccurate as lying on the back for prolonged periods can decrease blood flow to the uterus and should be avoided during pregnancy, especially in the third trimester. Option D is incorrect because kick counts should ideally begin earlier in the third trimester, around 28 weeks, rather than waiting until 36 weeks. Starting at 36 weeks may delay the detection of potential problems that could arise earlier. Educationally, understanding the rationale behind kick counts is vital for pregnant individuals to actively participate in monitoring their baby's movements and promptly report any concerns to their healthcare provider. Regular kick counts empower expectant mothers to be proactive in ensuring the well-being of their baby and can lead to timely interventions if issues arise.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn care, it is crucial for nurses to educate clients about signs of preterm labor to ensure timely intervention and optimal outcomes. The correct answer, option B, low back pain and cramping, should be reported immediately because it can indicate the onset of preterm labor, which poses risks to both the mother and the newborn. These symptoms may signal cervical changes and uterine contractions that could lead to preterm birth. Option A, frequent urination, is a common symptom during pregnancy due to hormonal changes and the growing uterus pressing on the bladder. While it can be uncomfortable, it is not typically a sign of preterm labor. Option C, increased appetite, is also a common occurrence in pregnancy and does not directly correlate with preterm labor. It is important for pregnant individuals to maintain a balanced diet to support their nutritional needs during pregnancy. Option D, Braxton Hicks contractions, are often referred to as "practice contractions" and are usually irregular, mild, and do not cause cervical changes. While they can be uncomfortable, they are a normal part of pregnancy and not necessarily indicative of preterm labor. Educating clients about these distinctions empowers them to recognize concerning symptoms, seek timely medical attention, and potentially prevent preterm birth complications through early intervention and management. This knowledge is essential for promoting the health and well-being of both the mother and the newborn.

Correct Answer: B

Rationale: In the context of pharmacology and maternal-newborn care, understanding the rationale behind performing Leopold's maneuvers during labor is crucial for safe and effective nursing practice. Leopold's maneuvers are a series of four systematic steps that help the healthcare provider determine the position and presentation of the fetus in the maternal abdomen. The primary purpose of this assessment is to ascertain the fetal position and presentation within the uterus. This information is essential for assessing fetal well-being, planning for labor and delivery, and identifying any potential complications that may arise during the birthing process. Option A, evaluating fetal heart rate, is incorrect because Leopold's maneuvers do not directly assess the fetal heart rate. Monitoring fetal heart rate is typically done using electronic fetal monitoring or handheld Doppler devices. Option C, checking for uterine contractions, is incorrect as Leopold's maneuvers are focused on fetal position and presentation rather than assessing uterine contractions. Uterine contractions are usually monitored separately using tocodynamometry or palpation techniques. Option D, assessing amniotic fluid volume, is also incorrect as Leopold's maneuvers do not provide information about amniotic fluid volume. This assessment is usually done through ultrasound or physical examination techniques specific to evaluating amniotic fluid levels. By understanding the purpose and significance of Leopold's maneuvers in determining fetal position and presentation, pharmacology students and healthcare providers can contribute to safe and competent care for mothers and newborns during the labor and delivery process. This knowledge is essential for promoting positive maternal and neonatal outcomes and ensuring the best possible care for both patients.