The nurse is caring for a client in labor and delivery with the following history: G2 P1000, 39 weeks' gestation in transition phase, FH 135 with early decelerations. The client states, 'I'm so scared. Please make sure the baby is OK!' Which of the following responses by the nurse is appropriate?

Correct Answer: B

Rationale: The correct response by the nurse, "B) The fetal heart rate is within normal limits," is appropriate for several reasons. Firstly, the nurse acknowledges the client's concern and provides reassurance by addressing the specific worry about the baby's well-being. By informing the client that the fetal heart rate is within normal limits, the nurse offers objective information to alleviate anxiety and promote a sense of security during labor. This response demonstrates empathy, effective communication, and clinical knowledge, all essential components of high-quality nursing care in obstetrics. The incorrect responses can be easily identified as inappropriate for this scenario. Option A dismisses the client's fear without providing any factual information or emotional support, which can further increase the client's anxiety. Option C is insensitive and inappropriate as it brings up a traumatic event without any relevance to the current situation, potentially causing distress to the client. Option D is also irrelevant as it does not address the client's immediate concerns and can lead to confusion or misinterpretation. In an educational context, this question highlights the importance of effective communication and emotional support in high-risk pregnancy scenarios. Nurses must possess not only clinical knowledge but also interpersonal skills to address the emotional needs of clients during labor and delivery. Understanding how to respond empathetically and provide accurate information can enhance the nurse-client relationship, improve patient outcomes, and promote a positive birthing experience.

Correct Answer: D

Rationale: In the context of high-risk pregnancy, it is crucial for the nurse to provide accurate information during counseling sessions. Option D, "The woman will be under anesthesia during the procedure," is the correct choice for several reasons. Tubal ligation is a surgical procedure that requires anesthesia to ensure the patient's comfort and safety during the operation. This information is essential to alleviate any concerns the woman may have about the procedure and to help her make an informed decision. Options A, B, and C are incorrect for various reasons. Option A is inaccurate because tubal ligation does not affect menstruation. Option B is incorrect as the surgery is not timed based on ovulation. Option C is misleading as tubal ligation is considered a permanent form of contraception and is not easily reversible. Providing this clarification helps the woman understand the significance of her decision and the implications it has on her reproductive health. In an educational context, this question highlights the importance of providing evidence-based information to patients during counseling sessions. Nurses play a vital role in patient education, and ensuring that accurate information is conveyed empowers patients to make informed decisions regarding their healthcare. Understanding the rationale behind each option helps students grasp the complexities of patient counseling in high-risk pregnancy scenarios.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Nausea and uterine tetany. Synthetic prostaglandins are commonly used for labor induction as they help ripen the cervix and stimulate uterine contractions. One of the common side effects of prostaglandins is uterine hyperstimulation, which can lead to uterine tetany (excessive, prolonged contractions) and nausea. Option B) Hypertension and vaginal bleeding is incorrect because prostaglandins typically do not cause hypertension, and vaginal bleeding would not be an expected side effect of their administration. Option C) Urinary retention and severe headache is also incorrect as these are not commonly associated with the administration of synthetic prostaglandins for labor induction. Option D) Bradycardia and hypothermia are not typical side effects of synthetic prostaglandins used for labor induction. From an educational perspective, understanding the side effects of medications used in high-risk pregnancies is crucial for nurses caring for these clients. Monitoring for and recognizing potential side effects promptly can help in preventing complications and providing safe care to both the mother and the baby.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Report swollen hands and face. This is the most important instruction for a patient with mild preeclampsia at 38 weeks' gestation on home bed rest. Swelling, particularly in the hands and face, can indicate worsening preeclampsia, which is characterized by high blood pressure and protein in the urine. Option A, eating a sodium-restricted diet, is not the priority in this situation as it does not directly address the immediate risk associated with preeclampsia. Option B, checking temperature 4 times daily, is not relevant to monitoring preeclampsia. Option D, limiting fluids to 1 liter per day, is incorrect as adequate hydration is important unless specifically advised by a healthcare provider due to severe symptoms. From an educational perspective, it is crucial for nurses to emphasize the signs and symptoms of worsening preeclampsia to pregnant women to ensure timely intervention and prevention of complications for both the mother and the baby. Teaching patients about when and how to report concerning symptoms empowers them to be active participants in their healthcare and promotes positive outcomes.

Correct Answer: C

Rationale: In a 42-week-gestation neonate, the nurse would expect to see loose and peeling skin (Option C). This finding is indicative of postmaturity, as the baby has been in utero for longer than the average 40 weeks. The skin of a post-term baby can appear dry, cracked, and peeling due to prolonged exposure to amniotic fluid, leading to desquamation. Option A, folded and flat pinnae, is incorrect as this is a normal finding in a term newborn. Option B, smooth plantar surfaces, is also incorrect as it is a common characteristic in newborns and not specific to post-term infants. Option D, short pliable fingernails, is not a distinguishing feature of post-term neonates. In an educational context, understanding the physical characteristics of neonates at different gestational ages is crucial for nurses caring for newborns, especially in high-risk situations like postmaturity. Identifying these signs helps nurses provide appropriate care and monitor for any complications associated with post-term births.