The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. What is the priority nursing action?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Notify the health care provider (HCP). The priority nursing action is to notify the healthcare provider because a fetal heart rate of 174 beats/minute at 38 weeks' gestation is above the normal range (120-160 beats/minute). This could indicate fetal distress, tachycardia, or other potential issues that require immediate medical attention. Option A) Document the finding is incorrect because simply documenting the finding without taking any further action could delay necessary interventions for the well-being of the fetus. Option B) Checking the mother's heart rate is not the priority in this situation. While it is important to assess the mother's vital signs, the fetal heart rate of 174 beats/minute requires immediate attention. Option D) Telling the client that the fetal heart rate is normal is incorrect and potentially misleading. Providing false reassurance could result in overlooking a critical issue. Educationally, this question highlights the importance of recognizing abnormal fetal heart rates and the need for prompt communication with the healthcare provider to ensure timely interventions and optimal outcomes for both the mother and the baby. It emphasizes the critical role of the nurse in advocating for the well-being of the mother and the fetus during pregnancy.

Correct Answer: A

Rationale: In the context of maternal newborn care, uterine atony, which is the inability of the uterus to contract effectively after delivery, can lead to excessive postpartum bleeding. The nurse's first action should be to massage the fundus until it is firm. This helps the uterus to contract, control bleeding, and prevent complications such as postpartum hemorrhage. Massage of the fundus stimulates contractions, promoting the expulsion of clots and reducing the risk of hemorrhage. Increasing IV fluid rate (option B) can support circulation but does not directly address the underlying issue of uterine atony. Notifying the healthcare provider (option C) is important but may cause a delay in immediate intervention. Administering oxytocin (option D) may be indicated but is typically done after fundal massage to enhance uterine contractions. Educationally, it is crucial for nurses to prioritize interventions based on the urgency of the situation. Understanding the pathophysiology of uterine atony and the rationale behind fundal massage empowers nurses to provide timely and effective care to postpartum clients. This scenario highlights the importance of quick decision-making and hands-on skills in managing obstetric emergencies.

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: B

Rationale: In this scenario, option B, "I can resume sexual activity when I stop bleeding," is the statement that indicates the need for further teaching. This statement is incorrect because resuming sexual activity should not be based solely on when the bleeding stops; it's essential to wait until after the postpartum check-up to ensure the body has adequately healed. Option A, "I will avoid heavy lifting for at least 6 weeks," is correct because postpartum women need to allow their bodies to heal, and heavy lifting can strain the healing process. Option C, "I should call my doctor if I experience a fever or foul-smelling discharge," is also correct as these symptoms can indicate an infection requiring medical attention. Option D, "I will schedule my postpartum visit in 6 weeks," is correct because postpartum visits are crucial for monitoring the mother's and baby's health. Educationally, this question emphasizes the importance of proper postpartum care and highlights common misconceptions that postpartum women may have regarding their recovery process. It underscores the significance of providing accurate information to ensure the well-being of both the mother and the newborn.

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.