The nurse is caring for a postpartum client with a perineal laceration. What comfort measure is most appropriate?

Correct Answer: D

Rationale: In the context of caring for a postpartum client with a perineal laceration, offering an ice pack for the perineum is the most appropriate comfort measure. The rationale behind this choice is based on the principle of vasoconstriction that occurs with the application of cold therapy. Ice packs help to reduce swelling, inflammation, and pain by constricting blood vessels, thereby decreasing blood flow to the area and numbing the nerves, which can provide relief to the perineal region. Encouraging warm sitz baths (Option A) can be beneficial for promoting healing and providing comfort in certain situations, but in the case of a perineal laceration, cold therapy is generally more effective initially due to its vasoconstrictive properties. Applying warm compresses to the perineum (Option B) and providing a heating pad for the lower abdomen (Option C) can be soothing in some instances, but they can potentially increase blood flow to the area, leading to more swelling and discomfort in the case of a perineal laceration. In an educational context, understanding the rationale behind choosing the most appropriate comfort measure for a specific situation is crucial for providing safe and effective care to postpartum clients with perineal lacerations. Nurses need to have a solid foundation in the principles of thermal therapy and its effects on the body to make informed decisions regarding comfort measures for their patients.

Correct Answer: A

Rationale: In the context of pharmacology and the VATI Maternal Newborn Assessment, understanding the signs of imminent birth during the second stage of labor is crucial for nurses. The correct answer is A) Client reports the urge to push. This finding indicates that the client is experiencing the Ferguson reflex, where the fetal head descends into the birth canal triggering the urge to push, signaling imminent birth. Option B) Contractions are irregular is incorrect because during the second stage of labor, contractions typically become stronger, longer, and more coordinated, rather than irregular. Option C) Fetal heart rate is 140 beats/minute is incorrect because fetal heart rate can vary during labor and being at 140 beats/minute does not specifically indicate imminent birth. Option D) Cervix is dilated to 8 cm is incorrect as well because although cervical dilation is a critical measure of progress in labor, being dilated to 8 cm does not specifically indicate that birth is imminent. Educationally, nurses must understand the physiological changes that occur during labor to provide safe and effective care to laboring women and newborns. Recognizing the signs of imminent birth allows nurses to prepare for the delivery and provide appropriate support and interventions.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn assessment, understanding the symptoms of preeclampsia is crucial for providing safe and effective care to pregnant clients. The correct answer to the question is B) Proteinuria. Proteinuria, the presence of excess protein in the urine, is a hallmark sign of preeclampsia. It indicates kidney damage, which is a common complication of this condition. Monitoring for proteinuria is essential in the assessment and management of preeclampsia to prevent severe complications for both the mother and the fetus. Option A) Hyperglycemia is not typically associated with preeclampsia. While gestational diabetes can occur in pregnancy, it is a separate condition that involves elevated blood sugar levels, not protein in the urine. Option C) Increased fetal movement is not a symptom of preeclampsia. Fetal movement can vary throughout pregnancy and can be influenced by various factors, but it is not a diagnostic criterion for preeclampsia. Option D) Hypotension, or low blood pressure, is also not a typical symptom of preeclampsia. In fact, hypertension, rather than hypotension, is a key feature of preeclampsia, along with proteinuria and other signs such as edema and organ dysfunction. Educationally, understanding the specific symptoms and diagnostic criteria for preeclampsia is essential for nurses caring for pregnant clients. Proper assessment, early recognition, and timely intervention are crucial in managing preeclampsia to prevent complications such as eclampsia and adverse outcomes for both the mother and the baby. This knowledge equips nurses with the skills to provide comprehensive care and support to pregnant clients at risk for or diagnosed with preeclampsia.

Correct Answer: A

Rationale: In this scenario, the priority nursing action is to perform a sterile vaginal examination (option A). This is because the client is experiencing intense pressure and the urge to push, which could indicate that she is in the second stage of labor, specifically the pushing phase. By conducting a sterile vaginal examination, the nurse can assess the client's cervical dilation and confirm if she is fully dilated and ready to push. This information is crucial for determining the appropriate stage of labor and guiding further interventions. Option B, instructing the client to breathe through the urge to push, is incorrect in this situation because the urge to push typically indicates that the client is in the second stage of labor and should be allowed to push if fully dilated. Delaying pushing when the urge is strong can lead to increased discomfort and potential complications. Option C, notifying the healthcare provider, is not the priority at this moment because immediate action is needed to assess the client's progress in labor and provide appropriate care. Healthcare provider notification can follow once the nurse has gathered essential information from the examination. Option D, increasing the oxytocin infusion rate, is also not the priority as the client is already experiencing the urge to push, suggesting that she is in the pushing stage of labor. Increasing oxytocin at this point could lead to hyperstimulation of the uterus and fetal distress. In the context of pharmacology, understanding the stages of labor and the appropriate nursing interventions is crucial for providing safe and effective care to laboring clients. Nurses must be able to prioritize actions based on the client's condition and stage of labor to promote positive maternal and neonatal outcomes.

Correct Answer: B

Rationale: In the context of pharmacology, understanding key assessment findings in obstetric emergencies like placental abruption is crucial for safe and effective nursing care. The correct answer, option B - hard, rigid abdomen with severe pain, is a key assessment finding in placental abruption due to the abrupt separation of the placenta from the uterine wall, leading to significant maternal and fetal risks. This finding indicates internal bleeding, resulting in a tense, painful abdomen due to blood accumulation. Immediate recognition of this sign is vital to prevent maternal shock and fetal distress. Option A - painless vaginal bleeding, is incorrect because placental abruption typically presents with painful bleeding. Painless vaginal bleeding is more commonly associated with conditions like placenta previa. Option C - clear amniotic fluid, is incorrect as it does not specifically relate to the assessment finding in placental abruption. Clear amniotic fluid is indicative of intact fetal membranes, not a placental emergency. Option D - regular uterine contractions, is incorrect as placental abruption is more commonly associated with hypertonic, non-reassuring contractions or even uterine tetany rather than regular contractions. Educationally, this question highlights the importance of thorough assessment skills in recognizing critical signs of obstetric emergencies like placental abruption. Nurses must be able to differentiate between various clinical presentations to provide timely and appropriate interventions, emphasizing the significance of continuous monitoring and prompt action in maternal and fetal well-being.