The nurse is educating a pregnant client about group B streptococcus (GBS) testing. When is this typically performed?

Correct Answer: B

Rationale: In the context of pharmacology related to maternal health, understanding the timing of group B streptococcus (GBS) testing is crucial for providing optimal care to pregnant clients. The correct answer is B) Between 35–37 weeks' gestation. This timing is essential because GBS colonization status can change during pregnancy, and testing closer to delivery provides a more accurate representation of the client's GBS status at the time of labor. Option A) At the first prenatal visit is incorrect because GBS status can change over the course of pregnancy, so testing at the beginning may not reflect the client's status later on, closer to delivery. Option C) During the second trimester is also incorrect as GBS testing is typically recommended later in the third trimester to ensure the most up-to-date information. Option D) After 40 weeks' gestation is incorrect as testing at this late stage may not allow for appropriate interventions or treatments to prevent vertical transmission of GBS to the newborn. Educationally, understanding the rationale behind the timing of GBS testing helps nurses and healthcare providers deliver evidence-based care to pregnant clients, reducing the risk of neonatal GBS infection. It emphasizes the importance of timing in prenatal care and highlights the dynamic nature of certain maternal health conditions during pregnancy. This knowledge empowers nurses to advocate for appropriate testing protocols and interventions to promote positive maternal and neonatal outcomes.

Correct Answer: A

Rationale: In this scenario, the priority action for the nurse caring for a client at 38 weeks' gestation reporting decreased fetal movement is to perform a nonstress test (NST). This test monitors the fetal heart rate in response to fetal movement, helping assess fetal well-being quickly and non-invasively. Performing an NST is crucial because decreased fetal movement could indicate fetal distress or compromise, which requires immediate evaluation to prevent adverse outcomes. The NST provides real-time information on fetal well-being, guiding further interventions or decisions. Instructing the client to drink orange juice (Option B) is not the priority in this situation as it may temporarily increase fetal activity but does not provide a comprehensive assessment of fetal well-being like an NST does. Scheduling an ultrasound (Option C) is important for assessing fetal anatomy and growth but may not provide immediate information on fetal well-being compared to an NST. Notifying the healthcare provider immediately (Option D) is important but performing an NST first allows the nurse to provide timely data to the provider for informed decision-making. Educationally, understanding the importance of prompt assessment and intervention in cases of decreased fetal movement is crucial for nurses caring for pregnant clients to ensure optimal outcomes for both the mother and the baby.

Correct Answer: C

Rationale: In this scenario, the most important assessment immediately after the placement of an epidural during labor is to monitor maternal blood pressure (Option C). This is crucial because epidural anesthesia can cause hypotension in the mother due to vasodilation, leading to decreased perfusion to the placenta and compromising fetal well-being. Assessing maternal temperature (Option A) is important but not the most critical immediate assessment post-epidural placement. Lower extremity weakness (Option B) is a common side effect of epidural anesthesia but does not take precedence over monitoring blood pressure. Checking fetal presentation (Option D) is also important but is secondary to ensuring maternal hemodynamic stability. Educationally, understanding the implications of epidural anesthesia on maternal blood pressure and fetal well-being is vital for nurses caring for laboring women. It emphasizes the need for close monitoring and prompt intervention to maintain a safe environment for both the mother and the baby during labor and delivery.

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: A

Rationale: In the scenario of a client at 38 weeks' gestation with suspected placental abruption, the priority nursing action is to assess maternal vital signs and fetal heart rate (Option A). This is crucial in determining the immediate status of both the mother and the baby. Placental abruption can lead to serious complications, including maternal hemorrhage and fetal distress, necessitating close monitoring of vital signs and fetal well-being. Preparing the client for immediate cesarean delivery (Option B) may be necessary depending on the severity of the abruption, but it should not be the immediate priority without assessing the current status of the mother and baby first. Administering oxygen (Option C) is important in cases of suspected placental abruption, but assessing the vital signs and fetal heart rate takes precedence. Inserting an indwelling urinary catheter (Option D) is not the priority in this situation and does not address the immediate threat to the mother and baby's health. In an educational context, understanding the hierarchy of nursing actions in emergencies like placental abruption is vital for providing safe and effective care. Prioritizing assessments allows for timely interventions and can improve outcomes for both the mother and the baby. Nurses need to be able to quickly identify the most critical actions to take in high-stress situations to provide optimal care.