The nurse is educating a client about postpartum care. What statement indicates the need for further teaching?

Correct Answer: B

Rationale: In this scenario, option B, "It is normal to have heavy bleeding for two weeks," indicates the need for further teaching. Postpartum bleeding, known as lochia, typically lasts for about 4-6 weeks, with the flow gradually decreasing over time. Heavy bleeding persisting for two weeks could signal a potential issue, such as retained placental tissue or infection, requiring medical attention. Option A, "I will call my doctor if I have a fever," is correct as fever can be a sign of infection postpartum, which needs prompt evaluation and treatment. Option C, "I will avoid lifting heavy objects," is also correct as heavy lifting can strain the healing tissues post-delivery. Option D, "Breast tenderness is common when my milk comes in," is correct as breast tenderness is a common occurrence during lactation due to engorgement and milk production. Educationally, it is essential for nurses to provide accurate information about postpartum care to ensure the well-being of both the mother and the newborn. Recognizing signs of complications early is crucial for timely intervention and optimal recovery. Empowering clients with correct knowledge enhances their ability to make informed decisions and promotes positive health outcomes.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Assess for cervical changes and fetal heart rate. The priority action for a client experiencing regular uterine contractions at 32 weeks' gestation is to assess for cervical changes and fetal heart rate to determine if the client is in preterm labor. This assessment is crucial for evaluating the status of the pregnancy and determining the appropriate course of action. Option A) Administer tocolytic medication as prescribed is incorrect because administering tocolytic medication should only be done after assessing for cervical changes and confirming preterm labor. Tocolytic medication is used to inhibit uterine contractions and delay preterm birth. Option B) Performing a sterile vaginal examination is not the priority in this situation as it can potentially introduce infection and is not necessary until the assessment of cervical changes and fetal heart rate has been completed. Option D) Encouraging ambulation to relieve discomfort is not the priority when there is a concern for preterm labor. While ambulation can sometimes help alleviate discomfort, it is not the appropriate action when assessing for preterm labor. Educationally, this scenario highlights the importance of prioritizing assessments in obstetric nursing. Understanding the sequence of actions in response to signs of preterm labor is critical in providing safe and effective care to pregnant clients. Early identification and timely intervention can significantly impact outcomes for both the mother and the baby.

Correct Answer: B

Rationale: In the context of pharmacology and the care of a client in the second stage of labor, the correct assessment indicating that birth is imminent is option B: "Fetal head is crowning." This is because crowning, which refers to the visible part of the baby's head at the vaginal opening, typically occurs just before birth is about to happen. This visual cue signifies that the baby is descending through the birth canal and delivery is imminent. Option A, "Cervix is dilated to 8 cm," is an important assessment indicating progress in labor but does not specifically indicate that birth is imminent. It shows the stage of dilation but not necessarily the exact timing of birth. Option C, "Contractions every 3-5 minutes," is a common pattern seen in the active phase of labor but does not provide a definitive indication that birth is about to happen in the immediate term. Option D, "Client reports back pain," is a vague symptom that can occur at various stages of labor and does not specifically signal that birth is imminent. In an educational context, understanding the nuances of labor assessments is crucial for nurses to provide appropriate care and support during childbirth. Recognizing the signs of imminent birth, such as crowning, helps nurses prepare for the delivery process and provide timely interventions if necessary. This knowledge is essential for ensuring the safety and well-being of both the mother and the newborn.

Correct Answer: A

Rationale: The correct answer is A) Verify signed informed consent. The priority nursing action before any invasive procedure like an amniocentesis is to ensure that the client has given informed consent. This is crucial as it upholds the principles of autonomy and beneficence, respecting the client's right to make decisions about their own healthcare. Without informed consent, the procedure cannot proceed ethically or legally. Option B) Administer prescribed analgesics is not the priority because while pain management is important for the client's comfort during the procedure, ensuring informed consent takes precedence. Option C) Encouraging the client to empty their bladder is important for the procedure but is not the priority over verifying informed consent. Option D) Positioning the client in a semi-Fowler's position is a procedural step for the amniocentesis but is not the priority before confirming informed consent. This scenario provides an important educational context about the ethical and legal responsibilities of healthcare providers in obtaining informed consent from clients before any medical procedure. It highlights the significance of respecting clients' autonomy and ensuring they have the necessary information to make informed decisions about their healthcare.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Check maternal blood pressure. When a client in labor receiving an epidural reports feeling lightheaded and nauseous, it could indicate hypotension, a common side effect of epidural anesthesia. Checking the maternal blood pressure is crucial to assess for hypotension, which can compromise both maternal and fetal well-being. Option A) Administer antiemetics as prescribed is incorrect because the priority is to address the potential hypotension first before treating the nausea. Option C) Increasing the oxytocin infusion rate is incorrect because the client is experiencing symptoms of hypotension, not related to the need for increased oxytocin. Option D) Encouraging the client to lie on her back is incorrect as this position can worsen hypotension. Educationally, understanding the potential side effects of epidural anesthesia, such as hypotension, is essential for nurses caring for laboring clients. Prompt assessment and intervention are crucial to ensure the safety of both the mother and the baby. Prioritizing interventions based on the client's condition and the potential risks involved is a fundamental aspect of maternal-newborn care.