The nurse is caring for a client with severe preeclampsia. What is the priority nursing action?

Correct Answer: B

Rationale: Assessing for signs of impending eclampsia, such as severe headache or visual changes, is critical to prevent seizures.

Correct Answer: D

Rationale: The education the nurse should provide to a person taking Ella for emergency contraception is to restart their COCs the next day and use a backup method, such as condoms, for 7 days. This is important to ensure continued protection against pregnancy, as Ella may potentially reduce the effectiveness of the COCs. Using a backup method during this time is essential to prevent unintended pregnancy.

Correct Answer: C

Rationale: True labor is characterized by regular, strong contractions that lead to cervical changes.

Correct Answer: A

Rationale: When a patient receives an epidural anesthesia during the first stage of labor, it can lead to temporary bladder dysfunction. The epidural can affect the patient's ability to feel the sensation of a full bladder and may impair the ability to voluntarily urinate. If the epidural is discontinued immediately after delivery during the fourth stage of labor, the patient may be at an increased risk of bladder distention due to the residual effects of the epidural. Therefore, monitoring for bladder distention and ensuring adequate bladder emptying is important to prevent complications.

Correct Answer: A

Rationale: The correct first action when a delivering patient's water breaks is to check the fetal heart tone. This is important to assess the well-being of the baby and ensure there are no signs of distress. Once the fetal heart tone is confirmed, the nurse can proceed with notifying the physician, changing bed linen, and encouraging the mother to go for a walk as needed. But the priority should always be to assess the fetal well-being in such a situation.