The nurse is caring for a client in labor receiving epidural anesthesia. What is the priority nursing assessment?

Correct Answer: B

Rationale: In the context of caring for a client in labor receiving epidural anesthesia, the priority nursing assessment is to monitor maternal blood pressure (Option B). The rationale behind this priority is that epidural anesthesia can cause maternal hypotension, which can lead to decreased perfusion to the fetus and potential fetal distress. By monitoring the maternal blood pressure regularly, the nurse can detect any changes promptly and intervene to maintain adequate perfusion to both the mother and the fetus. Assessing for bladder distention (Option A) is important to prevent bladder overdistention, but it is not the priority over monitoring maternal blood pressure in this scenario. Evaluating the fetal heart rate (Option C) is crucial, but maternal parameters should be stabilized first to ensure optimal fetal oxygenation. Checking for pain relief (Option D) is important for the client's comfort but is not the priority assessment when considering the potential adverse effects of epidural anesthesia on maternal blood pressure and fetal well-being. In an educational context, understanding the priorities in caring for a client receiving epidural anesthesia during labor is crucial for maternal and fetal safety. Nurses need to prioritize assessments based on the potential risks associated with the anesthesia method being used and implement timely interventions to ensure positive outcomes for both the mother and the baby.

Correct Answer: C

Rationale: In the context of pharmacology within maternal newborn care, understanding the physiological signs of labor progression is crucial for nurses. In this scenario, the correct answer is C) Fetal head is crowning. This finding indicates that the baby is descending through the birth canal and is on the verge of being born. Option A) Fetal head at station 0 may occur earlier in labor and does not necessarily indicate immediate readiness for delivery. Option B) Contractions every 3-5 minutes are indicative of active labor but do not specifically signal imminent delivery. Option D) Cervix dilated to 8 cm suggests progress in labor but does not provide a direct indication of readiness for delivery as crowning does. Educationally, nurses must grasp the significance of crowning as a definitive sign of imminent delivery during the second stage of labor. This knowledge allows for appropriate preparation, positioning, and support for the mother during the final moments of labor and birth. Understanding these key indicators enhances the nurse's ability to provide safe and effective care during this critical stage of childbirth.

Correct Answer: A

Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected sex. Choice B is incorrect as it is not as effective after 5 days. Choice C is incorrect because emergency contraception works primarily by preventing ovulation, not by preventing implantation. Choice D is incorrect because most emergency contraception methods are available over the counter.

Correct Answer: A

Rationale: The quality of spinnbarkeit refers to the elasticity of cervical mucus. Spinnbarkeit is a term used to describe the stretchability or stretchy quality of cervical mucus during ovulation. This elasticity is an important characteristic as it indicates the fertile window for a woman trying to conceive. High levels of spinnbarkeit allow for easier passage and survival of sperm, increasing the chances of conception. The other choices (B. amount, C. clarity, D. color) do not specifically refer to the stretchability or elasticity of cervical mucus, which is what is assessed when evaluating spinnbarkeit.

Correct Answer: D

Rationale: The correct statement the nurse knows that the clinician will inform the patient regarding the LNG-IUC is that there is no risk to the fetus if the IUC is left in place. The LNG-IUC (levonorgestrel-releasing intrauterine system) is a highly effective form of contraception that works by releasing progesterone locally in the uterus. The hormonal effect of the LNG-IUC is mostly limited to the uterus and very little of it circulates systemically. Therefore, there is no known increased risk of congenital defects or harm to the fetus if the IUC is left in place during pregnancy. The IUC can be left in place if the patient chooses to continue the pregnancy, provided there are no signs of infection or other complications that would necessitate its removal.