The nurse is educating a client about Rh incompatibility. What statement indicates understanding?

Correct Answer: B

Rationale: In this question about Rh incompatibility education, option B is the correct statement indicating understanding. The statement "I will need Rho(D) immune globulin if my baby is Rh positive" shows knowledge of the necessary treatment to prevent maternal sensitization to Rh-positive blood. Rho(D) immune globulin is given to Rh-negative mothers to prevent the development of Rh antibodies, which can cause harm in future pregnancies if the baby is Rh positive. Option A is incorrect because Rh incompatibility can occur in any pregnancy where the mother is Rh negative and the baby is Rh positive, not just in first pregnancies. Option C is incorrect as Rh incompatibility is not treated with antibiotics; it is managed by administering Rho(D) immune globulin and monitoring for complications. Option D is incorrect because Rh incompatibility can have serious effects on the baby, leading to hemolytic disease of the newborn if not appropriately managed. In the educational context, it is crucial for nurses to provide accurate information about Rh incompatibility to pregnant women to prevent potential complications in future pregnancies. Understanding the importance of Rho(D) immune globulin administration can help ensure the health of both the mother and the baby in cases of Rh incompatibility.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Preterm labor. At 36 weeks' gestation, frequent urination and lower back pain could be indicative of preterm labor, which is a serious concern in late pregnancy. The nurse should assess for signs such as regular contractions, abdominal cramping, vaginal bleeding, pelvic pressure, or a change in vaginal discharge to confirm preterm labor. Option B) Urinary tract infection is incorrect because although frequent urination can be a symptom, lower back pain is not typically associated with a UTI in pregnancy. UTIs usually present with symptoms like burning sensation during urination, cloudy or strong-smelling urine, and pelvic discomfort. Option C) Normal third-trimester changes is incorrect because while frequent urination can be a normal symptom in late pregnancy due to the pressure on the bladder from the growing uterus, lower back pain should not be dismissed as a typical discomfort. It is essential to rule out complications like preterm labor. Option D) Preeclampsia is incorrect as it usually presents with symptoms such as high blood pressure, proteinuria, swelling in the hands and face, headaches, and visual disturbances. Lower back pain and frequent urination are not typically associated with preeclampsia. In an educational context, understanding the signs and symptoms of preterm labor is crucial for nurses caring for pregnant women. Early identification and intervention can help prevent preterm birth and its associated complications. Nurses must be able to differentiate between normal pregnancy discomforts and potential red flags that require immediate attention to provide optimal care for both the mother and the baby.

Correct Answer: C

Rationale: In the context of a client in labor receiving epidural anesthesia, the priority nursing intervention is to frequently check maternal blood pressure (Option C). This is crucial because epidural anesthesia can cause hypotension, which can lead to decreased placental perfusion and compromise fetal oxygenation. Monitoring blood pressure allows for early detection of hypotension, enabling prompt intervention to maintain maternal and fetal well-being. Assessing for bladder distention (Option B) is important to prevent urinary retention, but it is not the priority when compared to monitoring blood pressure in this specific scenario. Monitoring maternal heart rate (Option A) is important, but blood pressure takes precedence due to its direct impact on perfusion. Encouraging frequent position changes (Option D) can help with labor progress and comfort but is not as critical as monitoring blood pressure in this situation. Educationally, this question highlights the importance of understanding the potential complications associated with epidural anesthesia during labor and the significance of prioritizing nursing interventions based on the client's condition and the potential impact on both maternal and fetal well-being. Nurses should be vigilant in monitoring vital signs and responding promptly to changes to ensure optimal outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Cholestasis of pregnancy. Severe itching without a rash in the third trimester should raise suspicion for cholestasis of pregnancy, a liver disorder that occurs during pregnancy and can lead to complications for both the mother and the fetus. Cholestasis of pregnancy is characterized by impaired bile flow, leading to a buildup of bile acids in the bloodstream, which can cause intense itching, typically on the palms and soles. Option B) Preeclampsia is a condition characterized by high blood pressure and signs of damage to another organ system, most commonly the liver and kidneys. While preeclampsia can present with symptoms such as headache, visual changes, and swelling, severe itching without a rash is not a typical symptom. Option C) Gestational diabetes is a condition where women without previously diagnosed diabetes develop high blood sugar levels during pregnancy. It is primarily associated with issues related to blood sugar control and typically does not present with severe itching without a rash. Option D) Fungal infection is unlikely in this case as severe itching without a rash is not a common presentation for a fungal infection, especially in the absence of other symptoms like redness, scaling, or discharge. Understanding these distinctions is crucial for nurses caring for pregnant clients, as prompt identification of conditions like cholestasis of pregnancy can lead to appropriate management and improved outcomes for both the mother and the baby. Nurses must be able to differentiate between various conditions that can arise during pregnancy to provide optimal care and support to their patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Contractions lasting 120 seconds. This finding would prompt the nurse to stop the oxytocin infusion because prolonged contractions can lead to uterine hyperstimulation, which can compromise fetal oxygenation and result in fetal distress. It is crucial to maintain an appropriate balance between uterine contractions for labor progress and ensuring fetal well-being during labor induction. Option A) Contractions every 2-3 minutes can be a normal response to oxytocin induction, but it alone does not indicate a need to stop the infusion. Option C) Baseline fetal heart rate of 140 beats/minute is within the normal range for a fetus at term and does not require stopping the infusion. Option D) Client reports mild back pain is a common discomfort during labor and is not a reason to discontinue the oxytocin infusion. Educationally, understanding the potential risks and complications of oxytocin administration during labor induction is essential for nurses caring for laboring women. It is crucial for nurses to recognize abnormal findings and take prompt actions to ensure the safety and well-being of both the mother and the fetus. Continuous monitoring and assessment skills are vital in obstetric care to provide safe and effective care during the labor and delivery process.