Choice A rationale

While the fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum, it is not the priority in this case. The fundus, which is the top part of the uterus, typically descends at a rate of approximately one fingerbreadth (or one cm) per day, and by the 12th postpartum day, it should no longer be palpable.

Choice B rationale

A saturated perineal pad in 30 minutes is a sign of excessive bleeding, also known as postpartum hemorrhage. This is a serious condition that can lead to shock and other complications if not treated promptly. Therefore, this finding should be prioritized by the nurse.

Choice C rationale

Approximated edges of an episiotomy are a normal finding in the postpartum period. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery. After delivery, the episiotomy is sutured and should heal without complications with proper care. However, this is not the priority finding in this scenario.

Choice D rationale

Deep tendon reflexes 4+ could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. However, since the client is already 4 hours postpartum, this is less likely to be the priority.

Choice A rationale

Administering Vitamin K is an important step in newborn care as it helps with blood clotting and prevents a rare but serious bleeding disorder called Vitamin K Deficiency Bleeding.

However, it is not the immediate priority after ensuring a patent airway.

Choice B rationale

Administering eye prophylaxis, typically in the form of antibiotic ointment, is a standard procedure in newborn care to prevent neonatal conjunctivitis. However, this is not the immediate priority after ensuring a patent airway.

Choice C rationale

Placing an identification bracelet on the newborn is crucial for ensuring the baby’s safety and preventing mix-ups. However, this is not the immediate priority after ensuring a patent airway.

Choice D rationale

Drying the skin of the newborn is the priority action after ensuring a patent airway. This is because newborns are wet with amniotic fluid at birth, and they can lose heat quickly through evaporation if not dried immediately. This can lead to hypothermia, which can be dangerous for the newborn.

Choice A rationale

Preparing for an emergency cesarean birth may be necessary in some cases of preeclampsia, particularly if there are signs of fetal distress or if the condition is not responding to treatment. However, in this scenario, the client’s symptoms are indicative of magnesium toxicity, not worsening preeclampsia.

Choice B rationale

Positioning the client in Trendelenburg (with the head lower than the feet) is not typically used in the management of preeclampsia or magnesium toxicity.

Choice C rationale

Discontinuing the medication infusion is the correct action in this scenario. The client’s symptoms (respiratory rate of 10/min and absent deep-tendon reflexes) are indicative of magnesium toxicity, a potential complication of magnesium sulfate therapy. Magnesium sulfate is used in the management of preeclampsia to prevent seizures, but it can cause toxicity if the levels become too high. If signs of toxicity occur, the infusion should be discontinued immediately.

Choice D rationale

Assessing maternal blood glucose may be necessary in some cases, particularly if the client has a history of diabetes. However, it is not the priority in this scenario, as the client’s symptoms are indicative of magnesium toxicity, not hyperglycemia.

The correct answers are A. Start breastfeeding with the nipple that is less sore, B. Change the infant’s position on the nipples, and C. Apply breast milk to the nipples before each feeding.

Choice A rationale:

Starting breastfeeding with the nipple that is less sore can help reduce discomfort. The baby tends to suck more vigorously at the beginning of a feeding, so starting with the less sore nipple can minimize pain.

Choice B rationale:

Changing the infant’s position on the nipples can help distribute the pressure more evenly and prevent further irritation of sore areas. Different positions can also help ensure a better latch.

Choice C rationale:

Applying breast milk to the nipples before each feeding can soothe and promote healing of sore nipples. Breast milk has natural antibacterial properties and can help keep the nipples moisturized.

Choice D rationale:

Massaging the breasts and nipples prior to feeding is not typically recommended for reducing nipple soreness. It can potentially cause more irritation and discomfort.

Choice E rationale:

Placing breast pads inside the nursing bra can help absorb leakage and keep the nipples dry, but it does not directly reduce soreness during breastfeeding. It is more of a preventive measure to maintain hygiene.

Choice A rationale

While a pattern of contractions can be a sign of labor, it is not the definitive sign of true labor. Contractions may also occur in false labor, also known as Braxton Hicks contractions. These contractions do not lead to changes in the cervix.

Choice B rationale

Changes in the cervix, including effacement (thinning) and dilation (opening), are the definitive signs of true labor. During true labor, contractions lead to progressive changes in the cervix, which allow for the baby to be born.

Choice C rationale

Rupture of the membranes, or “water breaking,” can occur in both true labor and false labor. Therefore, it is not the definitive sign of true labor.

Choice D rationale

The station of the presenting part refers to the position of the baby’s head (or other presenting part) in relation to the mother’s pelvis. While the station can change during labor as the baby descends into the pelvis, it is not the definitive sign of true labor.

The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30 minutes old...... However, it is less immediately life-threatening compared to meconium aspiration syndrome...... However, it is less immediately life-threatening compared to meconium aspiration syndrome. . Glucose is the main source of fuel for the brain and the body. In a newborn baby, low blood sugar can happen for many reasons. . However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice E rationale

Jaundice due to color of amniotic fluid is not a recognized medical condition........................... However, it is less immediately life-threatening compared to meconium aspiration syndrome.

The correct answer is Choice C. . . However, it is not the first action a nurse should take when late decelerations in the FHR are noted.

Choice B rationale

Applying a fetal scalp electrode is a procedure used for continuous fetal heart monitoring during labor. It provides a more accurate and consistent transmission of the fetal heart rate than external methods. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.

Choice C rationale

Changing the client’s position can help improve uteroplacental blood flow and fetal oxygenation. It is often the first action taken when late decelerations are noted in the FHR.

Choice D rationale

Increasing the rate of the IV infusion can help increase maternal blood volume and improve uteroplacental blood flow. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.

Choice A rationale

If a client reports feeling down and sad, having no energy, and wanting to cry, the nurse’s priority action should be to ask the client if she has considered harming her newborn. This is because these symptoms may indicate postpartum depression, a serious condition that can lead to harm to both the mother and the baby if left untreated.

Choice B rationale

While reinforcing postpartum and newborn care discharge teaching is important, it is not the priority action in this situation. The client’s emotional health needs to be addressed first.

Choice C rationale

Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action in this situation. The client’s immediate emotional health needs to be addressed first.

Choice D rationale

Anticipating a prescription by the provider for an antidepressant may be part of the treatment plan for this client, but it is not the priority action. The nurse first needs to assess the safety of the client and her newborn.

The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30

minutes old.

Choice B rationale

Birth weight can influence a newborn’s health, with low birth weight associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice C rationale

Gestational age can influence a newborn’s health, with preterm birth associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice D rationale

Fetal Undergrowth Anomaly (FUA) refers to a condition where a fetus does not grow at the expected rate during pregnancy. It can lead to various health problems for the newborn. However, it is less immediately life-threatening compared to meconium aspiration syndrome.