What immediate action should a nurse take for a mother reporting a severe headache postpartum?

Correct Answer: D

Rationale: In the scenario of a postpartum mother reporting a severe headache, the immediate action the nurse should take is to notify the healthcare provider immediately (Option D). This is the correct choice because a severe headache postpartum could be indicative of serious conditions such as postpartum preeclampsia or postpartum hemorrhage, both of which require prompt medical attention. Administering analgesics and monitoring blood pressure (Option A) could mask important symptoms and delay the necessary medical evaluation. Encouraging the mother to rest (Option B) is not appropriate when a severe headache could be a sign of a potentially life-threatening condition. Applying a cold compress (Option C) may provide temporary relief but does not address the underlying cause of the severe headache. In an educational context, it is crucial for nurses to recognize the potential complications that can arise postpartum and to prioritize prompt communication with healthcare providers when patients present with concerning symptoms. This case emphasizes the importance of timely assessment and intervention in the postpartum period to ensure the well-being of both the mother and the newborn.

Correct Answer: B

Rationale: In the context of a mother receiving magnesium sulfate therapy, the primary nursing concern is to monitor deep tendon reflexes hourly. This is crucial because magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and eclampsia. Monitoring deep tendon reflexes helps assess the level of neuromuscular blockade caused by magnesium sulfate. Decreased or absent reflexes indicate drug toxicity, which can progress to respiratory depression, cardiac arrest, and maternal death if not promptly addressed. Monitoring blood pressure every 4 hours (Option A) is important in pre-eclampsia but is not the primary concern when a mother is on magnesium sulfate therapy. Assessing respiratory rate and effort (Option C) is essential but not the primary concern compared to monitoring deep tendon reflexes. Preparing for delivery if signs of toxicity appear (Option D) is important but is an action taken after recognizing toxicity, not the primary concern for ongoing monitoring. Educationally, understanding the rationale behind closely monitoring deep tendon reflexes while a mother is on magnesium sulfate therapy reinforces the importance of pharmacological knowledge in maternal care. It emphasizes the critical role nurses play in assessing and managing potential medication side effects to ensure optimal maternal and fetal outcomes.

Correct Answer: C

Rationale: Vaginal spotting or light bleeding is one of the early signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of vaginal spotting or light bleeding may indicate the implantation of the fertilized egg in a location other than the uterus, leading to the suspicion of an ectopic pregnancy. It is essential for the nurse to recognize this early sign and promptly assess the client for further evaluation and intervention to prevent complications such as rupture and severe bleeding that can be life-threatening.

Correct Answer: A

Rationale: Terbutaline is used for the management of preterm labor, not postpartum hemorrhage (PPH). The medication that are contraindicated for the management of PPH include Cytotec, Hemabate, Pitocin, and Methergine. Terbutaline is not typically used for PPH as it is mainly utilized to delay preterm labor contractions and prevent premature birth.

Correct Answer: A

Rationale: The correct order of implementation in this scenario should focus on addressing the immediate physiological needs of the patient. The vital signs indicating hypovolemia from dehydration require prompt action to stabilize the patient's condition. Giving 1L of LR IV will help reestablish vascular volume, improve blood pressure, and address the underlying issue of dehydration. By addressing the hypovolemia first, the nurse can effectively start the process of stabilizing the patient before moving on to other interventions such as weighing the client, administering Maalox orally, or encouraging liquid intake.