The nurse is caring for a client with suspected placenta previa. What is the priority nursing intervention?

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.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn care, the priority intervention when assessing a client in labor with variable decelerations on the fetal monitor is to reposition the client (Option B). Repositioning the client, specifically onto their left side, helps to alleviate pressure on the vena cava, improving fetal oxygenation and potentially resolving the decelerations. Increasing the oxytocin infusion (Option A) can actually worsen variable decelerations by intensifying contractions, further compromising fetal oxygenation. Administering oxygen at 10 L/min (Option C) is generally a good intervention, but repositioning takes precedence in this scenario. Notifying the healthcare provider (Option D) is important, but it is not the immediate priority over repositioning the client to address the variable decelerations. Educationally, this rationale highlights the critical thinking skills needed in pharmacology and maternal newborn care. Understanding the physiological effects of different interventions is crucial in prioritizing care for both the mother and the unborn baby. By repositioning the client, nurses can actively contribute to improving fetal well-being during labor and delivery.

Correct Answer: A

Rationale: In the context of maternal fetal health, educating clients about kick counts is crucial for monitoring fetal well-being. The correct answer is A) Fewer than 10 movements in 2 hours because it aligns with the standard recommendation of feeling at least 10 movements within a 2-hour period. This frequency indicates adequate fetal activity and suggests a healthy baby. Contacting the healthcare provider in this scenario allows for prompt evaluation and intervention if needed. Option B) Fewer than 5 movements in 1 hour sets a threshold that is too low and may lead to unnecessary anxiety and frequent calls to the healthcare provider. It does not align with the standard kick count recommendations. Option C) No movements after drinking juice is not a reliable indicator of fetal well-being. Fetal movements can vary based on various factors, and the response to ingesting juice may not always be immediate or consistent. Option D) No movements for 12 hours is too long to wait before seeking medical attention. Delaying contact with the healthcare provider in such a situation could pose risks to the fetus if there is an issue with decreased fetal movement. Educationally, understanding the significance of kick counts empowers pregnant individuals to actively participate in monitoring their baby's health. By providing accurate information on when to contact the healthcare provider, nurses can help ensure timely interventions and promote positive maternal and newborn outcomes.

Correct Answer: B

Rationale: In the context of pharmacology and maternal-newborn care, it is crucial for nurses to understand the effects of medications like oxytocin on both the mother and the fetus during labor induction. The correct answer, B) Fetal heart rate of 100 beats/minute, requires the nurse to stop the infusion because a fetal heart rate of 100 beats/minute is considered bradycardia, which is a concerning sign indicating fetal distress. This situation necessitates immediate intervention to ensure the safety of the fetus. Option A) Contractions every 2 minutes may indicate hyperstimulation of the uterus, which can lead to fetal distress but does not explicitly mandate stopping the infusion. Option C) Maternal blood pressure of 120/80 mmHg is within the normal range and does not require stopping the oxytocin infusion. Option D) Client reports mild back pain is a common side effect of labor and not a reason to discontinue the oxytocin infusion. Educationally, this scenario highlights the importance of vigilant monitoring and prompt recognition of adverse effects during oxytocin administration for labor induction. Nurses should prioritize fetal well-being by closely assessing fetal heart rate patterns and being prepared to intervene promptly if signs of distress arise.

Correct Answer: B

Rationale: Birth control pills primarily work by preventing ovulation, thereby inhibiting the release of eggs for fertilization. Choice A is incorrect because birth control pills do not directly block sperm; they prevent ovulation. Choice C is partially correct but is not the main mechanism, as the primary function is to prevent ovulation. Choice D is incorrect because birth control pills do not alter the size of reproductive organs.