The nurse is monitoring a client during the second stage of labor. What finding indicates that birth is imminent?

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: 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.

Correct Answer: A

Rationale: In the context of pharmacology and maternal newborn assessment, the priority nursing action when assessing a client at 36 weeks' gestation who reports swelling in the hands and face is to check the client's blood pressure (Option A). This is crucial because sudden or severe swelling can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine that can lead to harmful complications for both the mother and the baby. Monitoring blood pressure allows for early detection and timely intervention to prevent adverse outcomes. Option B, reassuring the client that swelling is normal, is incorrect as it overlooks the potential seriousness of the situation and fails to address the need for further assessment. Option C, encouraging the client to reduce salt intake, while generally good advice for swelling, is not the priority in this scenario where preeclampsia needs to be ruled out. Option D, evaluating the fetal heart rate, is important but not the most immediate concern when potential preeclampsia is present. In the educational context, understanding the significance of assessing for signs of preeclampsia during pregnancy is essential for providing safe and effective care to expectant mothers. Nurses need to prioritize actions that address potential complications promptly to ensure the well-being of both the mother and the baby. This scenario highlights the importance of thorough assessment and critical thinking in maternity care, where quick decision-making can impact outcomes significantly.

Correct Answer: C

Rationale: The best sites for applying the contraceptive patch are the buttocks, arm, and leg. These areas have sufficient fat and are away from areas that might rub off the patch. Choice B (Neck) is incorrect as the neck is not recommended for patch application due to the potential for irritation and the high blood flow area. Choice C (Breast) is not recommended because the breast tissue may affect the adhesion of the patch.