When planning care for a laboring client, the nurse identifies the need to withhold solids food while the client is in labored. What is the most important reasons for this nursing intervention?

Correct Answer: C

Rationale: The correct answer is C) An increased risk of aspiration can occur if general anesthesia is needed. During labor, there is a risk that the client may need general anesthesia for emergency procedures such as cesarean section. In such cases, having solid food in the stomach can lead to aspiration, where food particles or stomach contents enter the lungs. This can cause serious complications such as pneumonia, respiratory distress, and even death. Option A is incorrect because nausea from analgesics can be managed with antiemetic medications and does not necessarily require withholding solid food. Option B is incorrect because while autonomic nervous system stimulation during labor does decrease peristalsis (movement of food through the digestive system), this alone is not the primary reason for withholding solids. Option D is incorrect because gastric emptying time decreasing during labor is not the main concern when deciding to withhold solids. From an educational standpoint, it is important for nurses to understand the rationale behind withholding solids during labor to prevent potential complications and ensure the safety of maternal and reproductive health clients. Nurses play a crucial role in advocating for best practices and implementing evidence-based interventions to promote positive outcomes for laboring clients.

Correct Answer: B

Rationale: The correct answer is B) Cries vigorously when stimulated. This is the best indication that the newborn is transitioning well to extrauterine life because crying helps the infant clear their airways, establish normal breathing patterns, and demonstrate neurological and respiratory function. Crying also indicates that the baby is responsive to external stimuli, which is a positive sign of their overall health and well-being. Option A, a heart rate of 220 beats/minute, is incorrect as it is too high for a newborn and could indicate distress or a medical issue. Option C, a positive Babinski reflex, is also incorrect as this reflex is normal in infants but doesn't necessarily indicate successful transition to extrauterine life. Option D, flexion of all four extremities, is a normal newborn reflex but alone does not provide as strong an indicator of successful transition as crying in response to stimulation. In an educational context, it is important for nurses and healthcare providers to understand the various signs and behaviors that indicate a newborn is transitioning well to life outside the womb. This knowledge helps them assess and monitor newborns effectively, ensuring they are adapting well to their new environment and are in good health.

Correct Answer: D

Rationale: In this scenario, the highest priority condition to assess for in the newborn with the given physical findings is hypoglycemia (Option D). Hypoglycemia is a critical concern in newborns, especially those who are small for gestational age like this newborn (4 pounds, 14 ounces). Low blood sugar levels can lead to serious complications such as brain injury or developmental delays. Given the infant's small size and potential limited glycogen stores, monitoring for hypoglycemia is crucial. The other options can be ruled out based on the provided physical findings: - Hyperthermia (Option A) is less likely as the infant's temperature is not mentioned and doesn't correlate with the other physical measurements. - Hyperbilirubinemia (Option B) typically presents with jaundice, which is not mentioned in the scenario. - Polycythemia (Option C) usually presents with signs like ruddy complexion, respiratory distress, and hypoglycemia, but in this case, the infant's physical findings do not strongly suggest polycythemia. Educationally, this question emphasizes the importance of recognizing the significance of physical assessment data in determining priority nursing actions for newborns, particularly in identifying and managing common newborn health issues promptly to prevent further complications. It highlights the critical nature of monitoring for hypoglycemia in at-risk newborns to ensure optimal outcomes.

Correct Answer: C

Rationale: The correct answer is C) Rapid increase in abdominal girth. In this scenario, the client is undergoing fertility treatment for anovulation and hyperprolactinemia. The medications being used can lead to ovarian hyperstimulation syndrome (OHSS), a serious complication characterized by fluid accumulation in the abdomen. A rapid increase in abdominal girth could be a sign of OHSS, which can be life-threatening if not addressed promptly. Option A) Episodes of headache and irritability are common side effects of fertility medications but are not typically considered urgent or life-threatening. Option B) Nausea and vomiting are also common side effects of fertility medications and are not typically indicative of a serious complication that requires immediate reporting. Option D) Persistent daytime fatigue is a non-specific symptom and is less likely to be associated with a critical condition like OHSS. Educationally, it is important for nurses to understand the potential side effects of fertility medications and the signs of complications such as OHSS. Prompt recognition and reporting of symptoms like a rapid increase in abdominal girth can help prevent serious consequences for the client. Nurses play a crucial role in educating clients about their fertility treatment, monitoring for side effects, and advocating for their well-being.

Correct Answer: D

Rationale: The correct action for the nurse to implement first in this scenario is option D: Perform fundal massage until firm. This is the most appropriate initial intervention because the client is experiencing excessive postpartum bleeding (hemorrhage) indicated by saturating two pads in 30 minutes and having a boggy uterus, which suggests uterine atony. Fundal massage helps to stimulate uterine contractions, which can help control bleeding by promoting uterine tone and reducing the risk of postpartum hemorrhage. Option A, having the client empty her bladder, is important in postpartum care but is not the priority in this situation where immediate management of hemorrhage is crucial. Option B, inspecting the perineum for lacerations, is also a valid assessment but does not address the primary concern of uterine atony causing hemorrhage. Option C, increasing oxytocin IV infusion, may be necessary but should come after addressing the immediate need for fundal massage to control bleeding. In an educational context, it is essential for nurses working in maternal and reproductive health to prioritize interventions based on the client's condition. Understanding the significance of timely interventions in managing postpartum complications like hemorrhage is critical for ensuring positive outcomes for both the mother and the newborn. Nurses should be proficient in recognizing signs of postpartum hemorrhage and be prepared to take prompt action to prevent further complications.