The nurse is monitoring a client in labor who is receiving oxytocin. What finding requires immediate intervention?

Correct Answer: C

Rationale: In the scenario of a laboring client receiving oxytocin, the finding that requires immediate intervention is a fetal heart rate of 100 beats/minute (Option C). This finding is concerning as a fetal heart rate of 100 beats/minute is indicative of fetal distress. Fetal distress can be a critical situation during labor and may necessitate prompt action to ensure the well-being of the fetus. Contractions lasting 90 seconds (Option A) may be intense but are not necessarily abnormal or an immediate cause for concern. Contractions every 2-3 minutes (Option B) are frequent but may be expected in active labor. Maternal heart rate of 85 beats/minute (Option D) falls within a normal range for an adult at rest and does not raise immediate alarm in the context of labor. Educationally, understanding the significance of fetal heart rate monitoring during labor is crucial for nurses caring for laboring clients. Sudden changes in fetal heart rate patterns can indicate fetal distress, prompting the need for quick assessment and intervention to optimize maternal and fetal outcomes. Monitoring and interpreting fetal heart rate patterns accurately are essential skills for nurses in obstetric care to ensure safe labor and delivery experiences.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Drink a glass of juice and lie down. This recommendation is based on the fact that maternal perception of fetal movements can be influenced by factors such as maternal stress, fatigue, or low blood sugar levels. By consuming juice and lying down, the client may be able to stimulate the baby's movements due to the natural increase in blood sugar levels and relaxation. Option A) Perform a nonstress test may not be the first step as it involves going to a healthcare facility, and initial self-care measures should be attempted first. Option C) Notify the healthcare provider immediately may be considered if the client's condition does not improve after trying self-care measures. Option D) Schedule an ultrasound is not the initial step unless other interventions have been ineffective. Educationally, it is important to teach pregnant clients about monitoring fetal movements and when to seek help. Clients should be informed about simple measures they can take at home, like consuming juice and lying down, to assess fetal well-being before seeking medical intervention. Understanding these steps is crucial for promoting maternal and fetal health during pregnancy.

Correct Answer: B

Rationale: In this scenario, option B, "Lower back pain and cramping," should be reported immediately as a sign of preterm labor. Lower back pain and cramping can indicate cervical changes or contractions that may lead to preterm labor, posing a risk to both the mother and the baby. This symptom warrants prompt medical evaluation to assess for preterm labor and take necessary interventions to prevent premature birth. The other options are not as concerning as option B. Increased fetal movements (option A) are generally considered a positive sign of fetal well-being. Mild swelling of the feet (option C) is common in pregnancy but is not typically indicative of preterm labor. Occasional Braxton Hicks contractions (option D) are normal, irregular, and painless contractions that occur throughout pregnancy, especially in the third trimester, and they are not a cause for immediate concern unless they become regular, intense, or are accompanied by other signs of preterm labor. In an educational context, it is crucial for nurses and expectant mothers to be aware of the signs and symptoms of preterm labor to ensure timely intervention and improve outcomes for both the mother and the baby. Teaching expectant mothers to recognize these signs empowers them to seek timely medical assistance when necessary, promoting maternal and neonatal well-being.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn care, it is crucial for nurses to educate patients about potential side effects of medications, including oral combination contraceptives. The correct answer, B) Thick vaginal discharge, is not a common side effect of oral contraceptives. A) Irregular bleeding is a common side effect of oral contraceptives, especially during the first few months of use as the body adjusts to the hormones. C) Nausea is another common side effect, which usually subsides after a few weeks. D) Breast tenderness can also occur as a side effect of hormonal contraceptives due to hormonal changes in the body. Educationally, it is important for nurses to understand the side effects of medications to provide comprehensive patient education. By knowing the side effects, nurses can effectively counsel patients on what to expect and when to seek medical advice. This helps promote patient adherence to the prescribed treatment plan and ensures patient safety and well-being.

Correct Answer: D

Rationale: Infection is a common complication after tubal ligation, indicated by redness and swelling at the surgical site. Choice A is incorrect as ileus is a bowel obstruction, not typically a complication of tubal ligation. Choice B, liver enlargement, is unrelated to tubal ligation. Choice C, constipation, may be a side effect but is not a primary concern after this procedure.