The nurse is caring for a client with preeclampsia. What is the most important assessment?

Correct Answer: D

Rationale: In the context of caring for a client with preeclampsia, the most important assessment among the options provided is monitoring the client's blood pressure (Option D). Preeclampsia is characterized by hypertension, and elevated blood pressure is a key indicator of the severity of the condition. Regular monitoring of blood pressure helps to assess the client's response to treatment and detect any worsening of the condition promptly. Option A, daily weight, while important in monitoring fluid status, is not as critical as blood pressure in the context of preeclampsia. Option B, urine protein levels, is also relevant in diagnosing preeclampsia, but it may not provide real-time information on the client's condition compared to blood pressure monitoring. Option C, fetal heart rate, is essential for assessing fetal well-being but is not the most crucial assessment when managing preeclampsia in the mother. Educationally, understanding the significance of monitoring blood pressure in clients with preeclampsia highlights the importance of recognizing and responding to hypertensive disorders in pregnancy. It emphasizes the need for timely and accurate assessments to ensure optimal maternal and fetal outcomes, aligning with evidence-based practice guidelines in maternal-newborn care.

Correct Answer: D

Rationale: In the context of pharmacology and maternal newborn care, understanding the benefits of skin-to-skin contact after delivery is crucial for nurses to educate clients effectively. The key benefit of skin-to-skin contact, as highlighted by option D, is stabilizing the neonatal temperature and heart rate. This practice helps newborns regulate their body temperature, heart rate, and breathing, promoting physiological stability and reducing stress. Option A, preventing postpartum hemorrhage, is incorrect in this context as skin-to-skin contact does not directly impact maternal bleeding after delivery. Option B, improving maternal milk production, is also incorrect as skin-to-skin contact primarily focuses on enhancing the newborn's well-being rather than directly affecting milk production. Option C, reducing the risk of neonatal jaundice, is not directly related to skin-to-skin contact benefits such as temperature regulation and bonding. Educationally, nurses should emphasize the importance of skin-to-skin contact as a evidence-based practice that promotes maternal-infant bonding, enhances breastfeeding initiation, and supports newborn physiological stability. By understanding the rationale behind this practice, nurses can effectively advocate for and educate clients on the benefits of skin-to-skin contact in the immediate postpartum period.

Correct Answer: A

Rationale: In the context of caring for a client with gestational hypertension, it is crucial for the nurse to be vigilant for signs of worsening condition that could indicate a progression to a more serious complication like preeclampsia. The symptom that should be reported immediately in this scenario is A) Headache unrelieved by acetaminophen. Severe headaches can be a warning sign of worsening hypertension or preeclampsia, which can lead to serious complications for both the mother and baby. Failure to address this symptom promptly could result in significant harm. Option B) Slight swelling of the hands is a common symptom in pregnancy and may not necessarily indicate a serious problem unless it is severe and accompanied by other concerning symptoms. Option C) Mild nausea after eating is also a common occurrence during pregnancy and is not typically a cause for immediate concern unless it is persistent, severe, or accompanied by other symptoms. Option D) Fatigue at the end of the day is a common symptom in pregnancy and is not typically indicative of a serious complication like preeclampsia. Educationally, it is important for nurses to understand the significance of monitoring for signs and symptoms of gestational hypertension and preeclampsia, as these conditions can have serious implications for both the mother and baby if not identified and managed promptly. Nurses should be equipped to differentiate between normal pregnancy symptoms and those that require immediate attention to provide safe and effective care to pregnant clients.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn care, the most effective intervention for a client in the first stage of labor experiencing severe lower back pain is to encourage frequent position changes (Option B). This intervention is based on the principles of optimizing fetal oxygenation and blood flow by relieving pressure on the mother's blood vessels and enhancing comfort during labor. Encouraging position changes helps to alleviate the intensity of back pain by redistributing the pressure on the lower back and promoting better fetal positioning for labor progression. It also assists in enhancing maternal blood circulation and reducing the risk of fetal distress. This non-pharmacological approach aligns with the goal of promoting physiologic birth and minimizing unnecessary medical interventions during labor. Administering an epidural block (Option A) may be effective for pain relief but is not the first-line option for addressing lower back pain in the initial stage of labor. Epidural blocks carry risks such as hypotension and prolonged labor, and should be reserved for cases where non-pharmacological interventions are ineffective. Applying a heating pad (Option C) may provide temporary relief for muscle tension but does not address the underlying causes of lower back pain in labor. Moreover, the use of heat modalities during labor should be monitored closely to prevent overheating and potential harm to the fetus. Performing a sterile vaginal exam (Option D) is not indicated for managing lower back pain in labor. Vaginal exams are typically conducted to assess cervical dilation and fetal descent, not for pain management purposes. In conclusion, understanding the rationale behind each intervention in the context of maternal newborn care is crucial for providing safe and effective care to laboring clients. Encouraging frequent position changes is the optimal choice to address severe lower back pain in the first stage of labor, promoting comfort, optimal fetal positioning, and minimizing the need for pharmacological interventions.

Correct Answer: B

Rationale: In the context of caring for a client with suspected placenta previa, the priority nursing intervention is to monitor fetal heart rate and maternal vital signs (Option B). This is crucial because placenta previa can lead to significant maternal hemorrhage and compromise fetal well-being due to poor placental perfusion. Monitoring fetal heart rate and maternal vital signs allows the nurse to assess for any signs of distress in both the mother and the baby. Any sudden changes in vital signs or fetal heart rate may indicate a worsening condition and prompt the need for immediate intervention or delivery. Performing a sterile vaginal examination (Option A) is contraindicated in placenta previa as it can lead to further disruption of the placenta and increase the risk of hemorrhage. Administering oxytocin to stop bleeding (Option C) is not appropriate without a clear understanding of the cause of bleeding, as oxytocin can exacerbate bleeding in placenta previa. Encouraging the client to ambulate (Option D) is not a priority when there is a risk of significant bleeding and compromised fetal well-being. In an educational context, understanding the priority interventions in obstetric emergencies like placenta previa is essential for nurses to provide safe and effective care to pregnant clients. Prioritizing assessments and interventions based on the client's condition can significantly impact outcomes for both the mother and the baby.