The nurse is educating a client about signs of labor. Which statement indicates understanding?

Correct Answer: C

Rationale: The correct answer is C) True labor contractions become stronger and more regular. This statement indicates understanding because true labor contractions are characterized by increasing intensity and regularity as labor progresses, leading to the eventual delivery of the baby. This understanding is crucial for the client to recognize the onset of true labor and seek appropriate medical care. Option A) False labor contractions do not cause cervical changes. False labor contractions, also known as Braxton Hicks contractions, are irregular and do not result in cervical dilation or effacement, unlike true labor contractions. Option B) True labor contractions do not decrease with activity. In fact, true labor contractions typically intensify with physical activity and do not subside with rest, unlike false labor contractions. Option D) False labor contractions are typically felt in the front of the abdomen, not in the back. Back pain is more commonly associated with true labor contractions as the baby descends into the birth canal. Educationally, understanding the differences between true and false labor contractions is vital for expectant mothers to distinguish between normal preparatory contractions and the onset of true labor. This knowledge empowers them to make informed decisions about when to seek medical assistance and when to go to the hospital for delivery.

Correct Answer: B

Rationale: In the context of caring for a client with severe preeclampsia, the priority nursing action is to assess for signs of impending eclampsia, making option B the correct choice. Eclampsia is a severe complication of preeclampsia characterized by seizures and poses immediate risks to both the mother and the baby. By closely monitoring for signs such as severe headaches, visual disturbances, epigastric pain, and hyperreflexia, the nurse can intervene promptly to prevent or manage eclamptic seizures. Administering antihypertensive medication (option A) may be necessary in managing severe preeclampsia, but it is not the priority over assessing for impending eclampsia. Monitoring urine protein levels (option C) is important in assessing the severity of preeclampsia, but it is not the immediate priority when the focus is on preventing eclamptic seizures. Encouraging ambulation (option D) is generally contraindicated in severe preeclampsia due to the risk of seizures and other complications associated with the condition. In an educational context, understanding the priority actions in managing complications of pregnancy like preeclampsia and eclampsia is crucial for nurses working in maternal newborn care. Prioritizing assessments and interventions based on the urgency of potential complications can significantly impact patient outcomes and safety. Nurses must be knowledgeable about the signs and symptoms of eclampsia and act swiftly to prevent serious consequences for both the mother and the baby.

Correct Answer: B

Rationale: The most reliable diagnostic test for suspected gestational diabetes is the Oral Glucose Tolerance Test (OGTT). This test involves the client fasting overnight and then drinking a glucose solution followed by blood draws to measure glucose levels at specific intervals. The OGTT is considered the gold standard for diagnosing gestational diabetes because it provides a more comprehensive assessment of the body's ability to regulate glucose levels over time. It can detect abnormalities in glucose metabolism that may not be captured by a single blood glucose measurement. In contrast, a random blood glucose test (Option A) may not provide an accurate representation of the client's glucose tolerance as it can be influenced by recent food intake. A fasting blood glucose test (Option C) only provides a snapshot of glucose levels at one point in time and may miss postprandial hyperglycemia common in gestational diabetes. Hemoglobin A1C (Option D) is not recommended for diagnosing gestational diabetes as it reflects average blood glucose levels over the past 2-3 months and may not capture recent changes in glucose metabolism during pregnancy. Educationally, understanding the rationale behind diagnostic tests for gestational diabetes is crucial for nurses caring for pregnant clients. By knowing the strengths and limitations of each test, nurses can advocate for appropriate screening and diagnostic procedures to ensure the best outcomes for both the mother and baby.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn care, the priority preoperative nursing action for a client undergoing a postpartum tubal ligation is to verify signed informed consent, which is option B. This is crucial because informed consent is a legal and ethical requirement that ensures the client fully understands the procedure, risks, benefits, and alternatives before proceeding. By verifying the signed informed consent, the nurse ensures that the client has made an informed decision and is aware of what will happen during the procedure, promoting patient autonomy and safety. Inserting an indwelling catheter (option A) is not the priority preoperative nursing action in this scenario unless specifically indicated by the healthcare provider based on the client's individual needs. Administering prescribed antibiotics (option C) and checking for maternal vital signs (option D) are important aspects of preoperative care but do not take precedence over verifying informed consent, which is essential for protecting the client's rights and ensuring a safe and ethical care environment. Educationally, understanding the importance of informed consent in healthcare settings is critical for nurses and other healthcare professionals. It is a fundamental aspect of patient care that upholds ethical principles and legal standards. By prioritizing informed consent, nurses demonstrate respect for the client's autonomy, promote shared decision-making, and contribute to the overall quality and safety of care provided to maternal newborn clients undergoing surgical procedures like tubal ligation.

Correct Answer: A

Rationale: In educating pregnant clients about kick counts, it is crucial to emphasize the significance of fetal movement as an indicator of fetal well-being. The correct answer is A) Fewer than 10 movements in 2 hours because a decrease in fetal movements could signal potential fetal distress and requires prompt evaluation by a healthcare provider. This frequency is a widely accepted guideline for when a mother should contact her healthcare provider. Option B) Fewer than 20 movements in 1 hour sets a higher threshold than the standard recommendation, potentially delaying necessary medical intervention. Option C) No movement in 4 hours poses a risk by allowing too much time to pass without monitoring fetal activity. Option D) No movement after eating a meal is not a standard criterion for assessing fetal well-being and may lead to unnecessary concerns or delays in seeking medical attention when needed. Educationally, it is important for nurses to teach pregnant clients the importance of regular kick counts, when to perform them, and what to do if there are concerning changes in fetal movement. This empowers clients to be proactive in monitoring their baby's health and seeking timely medical assistance when needed.