The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?

Correct Answer: A

Rationale: In this scenario, the correct intervention is to position the radiant warmer over the crib (Option A) first. This is crucial because the preterm infant is displaying signs of respiratory distress and decreased muscle tone, indicating a need for immediate thermal support to prevent further complications. Placing the infant under the radiant warmer will help maintain the infant's body temperature, which is vital for stabilizing their condition and preventing hypothermia. Assessing the infant's blood glucose level (Option B) is important but not the priority in this situation where respiratory distress and hypothermia are primary concerns. Nipple feeding 1 ounce 1% glucose in water (Option C) can wait until the infant's condition is stabilized. Placing the infant in a side-lying position (Option D) is not the most appropriate intervention given the presented symptoms. In an educational context, understanding the priority of interventions in neonatal care is crucial for nurses working in maternal and reproductive health. This scenario highlights the importance of prioritizing interventions based on the infant's immediate needs to ensure optimal outcomes in neonatal care.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take first is to obtain a blood glucose level (Option C). This is crucial because the jitteriness in the LGA infant could be due to hypoglycemia, which is common in infants of diabetic mothers. By obtaining a blood glucose level, the nurse can quickly assess if the infant's symptoms are related to low blood sugar and take appropriate action to address it promptly. Administering oxygen (Option A) may not address the underlying cause of the jitteriness and could delay necessary interventions. Feeding the infant glucose water (Option B) without knowing the actual blood glucose level could potentially worsen the situation if the infant's blood sugar is already high. Decreasing environmental stimuli (Option D) is not the priority in this situation where a medical intervention is required. Educationally, understanding the relationship between maternal diabetes, LGA infants, and potential hypoglycemia is essential for nurses caring for maternal and reproductive health clients. It highlights the importance of timely assessments and interventions to ensure the well-being of both the mother and infant.

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to implement is option D, which is to have the client transported to the hospital. Placenta previa is a serious condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding for both the mother and the baby. Immediate medical intervention is necessary to ensure the safety of the woman and her unborn child. Option A is incorrect because scheduling weekly prenatal appointments would not address the urgent need for immediate medical attention in the case of placenta previa. Option B, while addressing the woman's homelessness, is not the most critical action to take at this moment. Option C, obtaining a hemoglobin and hematocrit level, is important in general prenatal care but is not the priority when managing a case of placenta previa with active bleeding. From an educational perspective, this scenario highlights the importance of recognizing and responding to obstetric emergencies promptly. Nurses working with maternal and reproductive health clients need to be well-versed in identifying high-risk conditions like placenta previa and understanding the appropriate actions to take to ensure the safety and well-being of both the pregnant woman and her baby. Early recognition and intervention can significantly impact the outcomes in such critical situations.

Correct Answer: D

Rationale: In this scenario, the most important finding to report to the healthcare provider when assessing a pregnant woman at 39-weeks gestation admitted to labor and delivery is option D) 101.2 oral temperature. An elevated temperature in a pregnant woman could indicate an underlying infection, such as chorioamnionitis, which poses serious risks to both the mother and the baby. Prompt recognition and treatment of infections during pregnancy are crucial to prevent complications such as preterm birth or maternal sepsis. Option A) proteinuria, while important in assessing for preeclampsia, is not as acutely concerning as an elevated temperature in this context. Option B) 130/70 blood pressure falls within normal limits for pregnancy, and option C) pedal edema is a common finding in late pregnancy and is often not a cause for immediate concern unless it is sudden or severe. Educationally, this question highlights the importance of recognizing and prioritizing critical findings in maternal health assessments. It reinforces the significance of thorough assessments and prompt reporting of abnormal findings to ensure timely interventions and optimal outcomes for both the mother and the baby.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is option C: Clarify the client's wishes about receiving blood products. This is the most appropriate response because respecting the client's religious beliefs and autonomy is crucial in providing patient-centered care. Jehovah's Witnesses typically refuse blood transfusions due to religious beliefs, as they interpret certain Bible passages as prohibiting the ingestion of blood. Therefore, it is essential for the nurse to engage in a respectful and open conversation with the client to understand her preferences regarding medical interventions involving blood products. Option A, preparing to infuse multiple units of fresh frozen plasma, is incorrect because this action goes against the client's religious beliefs and autonomy. Option B, informing the client of the critical need for a blood transfusion, is not appropriate because it does not respect the client's religious beliefs and right to make informed decisions about her care. Option D, obtaining consent from the family to infuse packed red blood cells, is also incorrect as the decision should be based on the client's wishes, not the family's consent. Educationally, this scenario highlights the importance of cultural competence in nursing practice. Nurses must be aware of and respect the diverse cultural and religious beliefs of their clients to provide individualized and ethical care. It also underscores the significance of effective communication skills in discussing sensitive topics such as religious beliefs and treatment preferences with patients. By prioritizing patient autonomy and cultural sensitivity, nurses can uphold ethical standards and promote positive patient outcomes.