What is the nurse's immediate action for a boggy uterus?

Correct Answer: C

Rationale: Performing fundal massage to promote uterine firmness is the correct immediate action for a boggy uterus. A boggy uterus is a uterus that feels soft and relaxed instead of firm and contracted after childbirth, which can lead to excessive bleeding. Fundal massage helps to stimulate uterine contractions, which can help prevent or treat postpartum hemorrhage. Choice A, documenting the findings as normal, is incorrect because simply documenting the findings does not address the issue of a boggy uterus and the potential for postpartum hemorrhage. Immediate action is needed to promote uterine firmness. Choice B, continuing to administer the uterotonic medication, may be necessary in some cases, but the immediate action for a boggy uterus is fundal massage. Uterotonic medications can help promote uterine contractions, but fundal massage is a more direct and immediate intervention. Choice D, administering an analgesic for the birthing person's pain, is not the priority when dealing with a boggy uterus. While pain management is important, addressing the boggy uterus and potential postpartum hemorrhage takes precedence to ensure the birthing person's safety and well-being.

Correct Answer: B

Rationale: Labor dystocia refers to difficult or prolonged labor, which can increase the risk of complications for both the mother and baby. A 41-year-old woman is at high risk for labor dystocia due to advanced maternal age. As women age, their uterine muscles may not contract as effectively, leading to inefficient labor progress. This can result in prolonged labor, increased risk of instrumental deliveries (forceps or vacuum), and higher rates of cesarean sections. Choice A, 38-week gestation, is not necessarily a risk factor for labor dystocia. Full-term pregnancy is considered to be between 37-42 weeks, so a 38-week gestation is within the normal range and does not inherently increase the risk of labor dystocia. Choice C, prenatal anemia, can contribute to maternal fatigue and weakness during labor, but it is not a direct risk factor for labor dystocia. Anemia can be managed with appropriate prenatal care and iron supplementation to reduce its impact on labor. Choice D, no prenatal care, is a significant risk factor for various complications during pregnancy and labor, but it is not directly associated with labor dystocia. Lack of prenatal care can lead to undiagnosed medical conditions, inadequate monitoring of fetal well-being, and missed opportunities for interventions that could prevent labor dystocia. In conclusion, a 41-year-old woman is at high risk for labor dystocia due to advanced maternal age, while the other choices are not directly linked to this specific complication. It is important for healthcare providers to recognize these risk factors and provide appropriate management to optimize outcomes for both the mother and baby.

Correct Answer: B

Rationale: Amniotomy is a procedure where the amniotic sac is artificially ruptured to induce or accelerate labor. Choice A, a six-hour decrease of labor, is incorrect because while amniotomy can sometimes speed up labor, it is not guaranteed to reduce labor by a specific amount of time. It may vary depending on individual factors. Choice C, elevated blood pressure, is also incorrect. Amniotomy does not directly cause elevated blood pressure. Elevated blood pressure during labor can be a sign of other complications such as preeclampsia, but it is not a direct result of amniotomy. Choice D, second stage labor dystocia, is also incorrect. Amniotomy is more commonly associated with the first stage of labor rather than the second stage. Second stage labor dystocia is usually related to issues with the baby's position or maternal pushing efforts, not the rupture of the amniotic sac. The correct answer is B, chorioamnionitis. Amniotomy increases the risk of chorioamnionitis, which is an infection of the fetal membranes. This is because the protective barrier of the amniotic sac is broken, providing a pathway for bacteria to enter and infect the amniotic fluid. Chorioamnionitis can lead to serious complications for both the mother and baby, including sepsis and preterm birth. It is important for healthcare providers to closely monitor for signs of infection after an amniotomy.

Correct Answer: A

Rationale: A: Assessing deep tendon reflexes for hyperreflexia is the correct nursing intervention for preeclampsia because hyperreflexia is a common sign of worsening preeclampsia. This assessment helps in early detection of neurological complications such as eclampsia, which is a severe form of preeclampsia characterized by seizures. Prompt identification of hyperreflexia allows for timely intervention to prevent further complications. B: Providing frequent IV fluid boluses is not the appropriate intervention for preeclampsia. In fact, excessive fluid administration can exacerbate hypertension and lead to fluid overload, putting the patient at risk for pulmonary edema. Careful fluid management is crucial in managing preeclampsia, but it should be done judiciously and based on the patient's fluid status. C: Educating the laboring person that preeclampsia is only a concern for pregnancy, not labor, is incorrect. Preeclampsia is a serious pregnancy complication characterized by high blood pressure and signs of damage to other organ systems. It can occur before, during, or after labor, and it requires close monitoring and management throughout the perinatal period to ensure the safety of both the parent and the baby. D: Discouraging pain medication in order to assess for a headache is not a recommended nursing intervention for preeclampsia. Headaches are a common symptom of preeclampsia, and pain management should be provided to alleviate discomfort and improve the patient's overall well-being. Delaying pain relief can lead to unnecessary suffering and does not contribute to the assessment and management of preeclampsia.

Correct Answer: C

Rationale: Intrauterine fetal demise refers to the death of a fetus inside the uterus before birth. One of the signs of intrauterine fetal demise is decreased or absent fetal movement. This occurs because the fetus is no longer alive and therefore cannot move. Fetal movement is a reassuring sign of fetal well-being, so a lack of movement is concerning. Increased fetal heart rate (Choice A) is not a sign of intrauterine fetal demise. In fact, a rapid fetal heart rate can indicate fetal distress or other issues, but it is not typically associated with fetal demise. Vaginal bleeding (Choice B) can be a sign of various complications during pregnancy, such as placental abruption or placenta previa, but it is not a specific sign of intrauterine fetal demise. Macrosomia (Choice D) refers to a baby who is significantly larger than average at birth. This is not a sign of intrauterine fetal demise but rather a risk factor for complications during delivery, such as shoulder dystocia. In summary, the correct answer is C because decreased or absent fetal movement is a significant sign of intrauterine fetal demise, while the other choices are not specific indicators of this condition.