The nurse is monitoring a laboring client with oxytocin infusion. What finding requires immediate intervention?

Correct Answer: C

Rationale: In a laboring client with oxytocin infusion, a fetal heart rate of 100 beats/minute requires immediate intervention. This finding indicates fetal distress, which could be a sign of hypoxia or other complications. Monitoring fetal well-being is crucial during labor, and a heart rate of 100 beats/minute is below the normal range, necessitating prompt action to prevent potential harm to the baby. Contractions lasting 60 seconds are within a normal range and are not typically a cause for immediate concern. Contractions every 2 minutes could indicate tachysystole, but alone may not always require immediate intervention unless associated with other signs of distress. The client reporting back pain is a common occurrence during labor and does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. Educationally, this scenario highlights the importance of continuous fetal monitoring during labor and the need for nurses to recognize signs of fetal distress promptly. Understanding normal labor parameters and variations is essential for providing safe and effective care to laboring patients and their babies.

Correct Answer: D

Rationale: In the context of caring for a client with preeclampsia, the most important assessment among the options provided is monitoring the client's blood pressure (Option D). Preeclampsia is characterized by hypertension, and elevated blood pressure is a key indicator of the severity of the condition. Regular monitoring of blood pressure helps to assess the client's response to treatment and detect any worsening of the condition promptly. Option A, daily weight, while important in monitoring fluid status, is not as critical as blood pressure in the context of preeclampsia. Option B, urine protein levels, is also relevant in diagnosing preeclampsia, but it may not provide real-time information on the client's condition compared to blood pressure monitoring. Option C, fetal heart rate, is essential for assessing fetal well-being but is not the most crucial assessment when managing preeclampsia in the mother. Educationally, understanding the significance of monitoring blood pressure in clients with preeclampsia highlights the importance of recognizing and responding to hypertensive disorders in pregnancy. It emphasizes the need for timely and accurate assessments to ensure optimal maternal and fetal outcomes, aligning with evidence-based practice guidelines in maternal-newborn care.

Correct Answer: B

Rationale: The correct answer is B) Amniotic fluid index and fetal well-being. The biophysical profile (BPP) is a prenatal test that assesses the well-being of the fetus by evaluating specific parameters including fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume (amniotic fluid index), and fetal heart rate reactivity. This test provides valuable information about the fetal health and helps in determining the need for further intervention or monitoring. Option A) Fetal genetic disorders is incorrect because the BPP does not assess genetic disorders; it focuses on the immediate well-being of the fetus. Option C) Maternal blood flow is incorrect as the BPP specifically evaluates fetal parameters and not maternal factors. Option D) Cervical length is incorrect as this parameter is not part of the BPP assessment; cervical length is more relevant in assessing the risk of preterm labor. Educationally, understanding the purpose and components of the BPP is crucial for nurses caring for pregnant women. This test aids in identifying potential fetal distress or compromise, guiding timely interventions to optimize outcomes for both the mother and the baby. Nurses need to interpret BPP results accurately to provide appropriate care and support to pregnant clients.

Correct Answer: D

Rationale: In the context of pharmacology and maternal newborn care, understanding the benefits of skin-to-skin contact after delivery is crucial for nurses to educate clients effectively. The key benefit of skin-to-skin contact, as highlighted by option D, is stabilizing the neonatal temperature and heart rate. This practice helps newborns regulate their body temperature, heart rate, and breathing, promoting physiological stability and reducing stress. Option A, preventing postpartum hemorrhage, is incorrect in this context as skin-to-skin contact does not directly impact maternal bleeding after delivery. Option B, improving maternal milk production, is also incorrect as skin-to-skin contact primarily focuses on enhancing the newborn's well-being rather than directly affecting milk production. Option C, reducing the risk of neonatal jaundice, is not directly related to skin-to-skin contact benefits such as temperature regulation and bonding. Educationally, nurses should emphasize the importance of skin-to-skin contact as a evidence-based practice that promotes maternal-infant bonding, enhances breastfeeding initiation, and supports newborn physiological stability. By understanding the rationale behind this practice, nurses can effectively advocate for and educate clients on the benefits of skin-to-skin contact in the immediate postpartum period.

Correct Answer: A

Rationale: In the context of caring for a client with gestational hypertension, it is crucial for the nurse to be vigilant for signs of worsening condition that could indicate a progression to a more serious complication like preeclampsia. The symptom that should be reported immediately in this scenario is A) Headache unrelieved by acetaminophen. Severe headaches can be a warning sign of worsening hypertension or preeclampsia, which can lead to serious complications for both the mother and baby. Failure to address this symptom promptly could result in significant harm. Option B) Slight swelling of the hands is a common symptom in pregnancy and may not necessarily indicate a serious problem unless it is severe and accompanied by other concerning symptoms. Option C) Mild nausea after eating is also a common occurrence during pregnancy and is not typically a cause for immediate concern unless it is persistent, severe, or accompanied by other symptoms. Option D) Fatigue at the end of the day is a common symptom in pregnancy and is not typically indicative of a serious complication like preeclampsia. Educationally, it is important for nurses to understand the significance of monitoring for signs and symptoms of gestational hypertension and preeclampsia, as these conditions can have serious implications for both the mother and baby if not identified and managed promptly. Nurses should be equipped to differentiate between normal pregnancy symptoms and those that require immediate attention to provide safe and effective care to pregnant clients.