The nurse is teaching a client about signs of labor. Which symptom indicates true labor?

Correct Answer: C

Rationale: In the context of pharmacology, understanding the signs of labor is crucial for nurses to provide effective care to pregnant clients. In this scenario, the correct answer is C) Cervical dilation and effacement. This is because true labor is characterized by progressive cervical changes, including dilation (opening of the cervix) and effacement (thinning of the cervix). These changes indicate that the body is preparing for childbirth and that labor is advancing. Option A) Irregular contractions that stop with activity are indicative of false labor, also known as Braxton Hicks contractions. These contractions are typically irregular, do not increase in intensity, and do not cause cervical changes. Option B) Contractions felt in the abdomen only do not specifically indicate true labor. True labor contractions are typically felt in the lower back and radiate to the front of the abdomen, with a regular pattern and increasing intensity over time. Option D) Absence of fetal movement is not a sign of true labor but rather a separate consideration related to fetal well-being. Fetal movement is an important indicator of fetal health and should be monitored throughout pregnancy, but it is not a specific sign of labor. Educationally, it is important for nurses to understand the distinguishing characteristics of true labor to differentiate it from false labor and provide appropriate care and guidance to pregnant clients. By recognizing the signs of true labor, nurses can help clients prepare for childbirth and ensure a safe and positive birthing experience.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn assessment, understanding the symptoms of preeclampsia is crucial for providing safe and effective care to pregnant clients. The correct answer to the question is B) Proteinuria. Proteinuria, the presence of excess protein in the urine, is a hallmark sign of preeclampsia. It indicates kidney damage, which is a common complication of this condition. Monitoring for proteinuria is essential in the assessment and management of preeclampsia to prevent severe complications for both the mother and the fetus. Option A) Hyperglycemia is not typically associated with preeclampsia. While gestational diabetes can occur in pregnancy, it is a separate condition that involves elevated blood sugar levels, not protein in the urine. Option C) Increased fetal movement is not a symptom of preeclampsia. Fetal movement can vary throughout pregnancy and can be influenced by various factors, but it is not a diagnostic criterion for preeclampsia. Option D) Hypotension, or low blood pressure, is also not a typical symptom of preeclampsia. In fact, hypertension, rather than hypotension, is a key feature of preeclampsia, along with proteinuria and other signs such as edema and organ dysfunction. Educationally, understanding the specific symptoms and diagnostic criteria for preeclampsia is essential for nurses caring for pregnant clients. Proper assessment, early recognition, and timely intervention are crucial in managing preeclampsia to prevent complications such as eclampsia and adverse outcomes for both the mother and the baby. This knowledge equips nurses with the skills to provide comprehensive care and support to pregnant clients at risk for or diagnosed with preeclampsia.

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.