When teaching a gravid client how to perform kick (fetal movement) counts which instruction should the nurse includes.

Correct Answer: D

Rationale: The correct answer is D: If 10 kicks are not felt within 1 hr, drink orange juice and count for another hour. Rationale: This instruction is correct because the intake of glucose-rich orange juice can stimulate fetal movement due to the increase in blood sugar levels, making it easier to perceive fetal kicks. This step aims to ensure the well-being of the fetus by prompting movement if it is not initially detected. Option A is incorrect because exercising before counting kicks may lead to false perceptions of fetal movements due to increased maternal heart rate and movement, which can be confusing for the client. Option B is incorrect as counting movements for one hour before breakfast is not recommended. Fetal movement counts are typically advised to be done at a time when the fetus is most active, which may not necessarily be in the morning before breakfast. Option C is incorrect because avoiding caffeinated drinks for 24 hours before conducting the kick test is not necessary. Caffeine intake does not significantly impact fetal movements, and this instruction may add unnecessary restrictions for the client. Educational Context: Teaching pregnant clients how to perform kick counts is crucial for monitoring fetal well-being. Providing accurate instructions ensures that clients can effectively assess fetal movements and promptly seek medical attention if changes occur. Encouraging clients to follow evidence-based practices, such as drinking orange juice to stimulate fetal movements, empowers them to actively participate in monitoring their baby's health.

Correct Answer: D

Rationale: In the case of a laboring client who is GBS+ (Group B streptococcus), the immediate treatment indicated is the administration of antibiotics (Option D). This is because Group B streptococcus is a bacterium that can be passed to the newborn during labor and delivery, potentially causing serious infections such as pneumonia, sepsis, or meningitis. Administering antibiotics to the mother during labor can significantly reduce the risk of transmission to the newborn. Option A, administration of Pitocin, is used to induce or augment labor and is not directly related to the treatment of GBS infection. Option B, artificial rupture of the membrane, can be a part of the labor process but does not address the specific concern of GBS infection. Option C, amnioinfusion for the baby, is a procedure used to address issues such as low amniotic fluid levels and is not the immediate treatment for GBS infection in a laboring client. In an educational context, understanding the importance of timely administration of antibiotics in GBS+ laboring clients is crucial for nurses caring for maternal and reproductive health clients. This knowledge ensures the safety of both the mother and the newborn by preventing potential complications associated with GBS infection. Nurses must be able to recognize the significance of this intervention to provide optimal care and promote positive maternal and neonatal outcomes.

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: B

Rationale: In this scenario, the correct answer is B) Contraction duration of 100 seconds. Prolonged contractions can lead to uteroplacental insufficiency, reducing fetal oxygenation. If contractions last too long, there is not enough time for the placenta to replenish oxygen to the baby. This can result in fetal distress and compromise the well-being of the baby. Option A) Uterus soft would not be a reason to discontinue oxytocin as this is a normal finding during the initial stages of labor. Option C) Four contractions in 10 minutes could indicate tachysystole, which is a concern, but it is not as immediately dangerous as prolonged contractions. Option D) Early deceleration of fetal heart rate is concerning but may not necessarily warrant immediate discontinuation of oxytocin unless it persists or worsens. Educationally, this question highlights the importance of monitoring both maternal and fetal well-being during labor induction or augmentation. Understanding the implications of prolonged contractions on fetal oxygenation is crucial for safe maternal and neonatal outcomes.

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.