Choice A rationale

A client who is 3 weeks postpartum and feeling tired all the time is a common scenario. Adjusting to a new baby can be challenging and it’s normal for new mothers to feel overwhelmed and fatigued. The nurse’s response should be empathetic and supportive,

encouraging the client to share more about her situation. This could help the nurse understand the client’s support system and provide appropriate advice or resources.

Choice B rationale

While it’s important to ensure that the client isn’t overexerting herself with chores, suggesting that she shouldn’t be doing any at all might not be practical or feasible. The presence and involvement of family members can vary greatly, and while their help can be beneficial, it’s not the only factor in managing postpartum fatigue.

Choice C rationale

It’s indeed common for new mothers to feel worn out for the first few months. However, simply advising the client to rest when the baby is sleeping might not address the root cause of her fatigue. It’s also important to consider other factors such as nutrition, emotional well- being, and available support.

Choice D rationale

Telling the client that it’s normal to feel fatigued for the first few weeks might minimize her feelings. Each person’s postpartum experience is unique, and it’s crucial to validate her feelings and provide individualized care.

The correct answer is Choice C.

Choice A rationale: Reviewing the pattern of the fetal heart rate is important but not the immediate first step when a client in active labor needs to use the restroom. The nurse should first assess the progress of labor.

Choice B rationale: Checking the client's bladder is necessary, especially if the bladder is full, as it can affect labor progress. However, the priority is to assess the cervix first to ensure the client is not in an advanced stage of labor before addressing bladder concerns.

Choice C rationale: Determining the dilation of the cervix is crucial. The need to use the restroom may indicate increased pressure from the presenting part of the fetus, suggesting rapid labor progression. This assessment will help determine if it is safe for the client to ambulate to the restroom or if other immediate actions are needed.

Choice D rationale: Testing the pH of the vaginal fluid can be part of assessing for the presence of amniotic fluid, but it is not the first step when a client in active labor expresses the need to use the restroom. Cervical assessment takes priority in this situation.

Choice A rationale

A pudendal block is a type of anesthesia that results in a loss of sensation confined to the vagina and perineum. It’s often used during the second stage of labor or for episiotomy repair.

Choice B rationale

A paracervical block provides anesthesia to the cervix and the lower part of the uterus, but it does not specifically target the vagina and perineum.

Choice C rationale

An epidural block provides a band of numbness from the bellybutton to the upper legs, allowing the patient to be awake and alert throughout labor. It’s not confined to the vagina and perineum.

Choice D rationale

A saddle block is a type of spinal anesthesia that numbs the inner thighs, buttocks, and area around the rectum (the “saddle” area), but it’s not confined to the vagina and perineum.

Choice A rationale

In a situation where a client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery, the nurse’s initial action should be to contact spiritual support services. This can provide much-needed emotional and spiritual support to the client during this difficult time.

Choice B rationale

While providing information about an autopsy might be necessary at some point, it should not be the initial action. The first response should be focused on providing emotional support.

Choice C rationale

Discussing neonatal resuscitation options might not be appropriate in this scenario, especially if it’s not expected that the fetus will survive. The initial focus should be on providing emotional support.

Choice D rationale

Contacting the organ donation organization is not the initial action to take in this situation. The first response should be providing emotional and spiritual support to the client.

Choice A rationale

Cervical dilation is a sign of labor, but a dilation of 1 cm alone does not confirm active labor. It could be the early phase of labor or false labor.

Choice B rationale

Contractions that decrease with walking are typically associated with false labor. In true labor, contractions usually get stronger regardless of activity level.

Choice C rationale

While 2+ pitting edema in the lower extremities can be seen in pregnancy, it is not a reliable indicator of labor. It could be due to fluid retention or other conditions.

Choice D rationale

The status of the membranes (intact or ruptured) does not necessarily indicate whether a woman is in labor. Some women may experience membrane rupture before labor begins.

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Rationale:

• Choice A: Clean up the spit-up and assist the mother with the diaper change is not the first priority. While cleaning is important, ensuring the baby's airway is clear and preventing aspiration (inhaling vomit into the lungs) is more critical.
• Choice B: Position the newborn on the side and suction the mouth and nares with a bulb syringe is only necessary if the baby shows signs of respiratory distress, such as coughing, wheezing, or difficulty breathing. Unless aspiration is suspected, suctioning can irritate the nasal passages and worsen the situation.
• Choice C: Position the newborn with the head lower than the feet can actually increase the risk of aspiration. Fluids can pool in the back of the throat and be more easily inhaled.
• Choice D: Sit the newborn upright and burp by gently rubbing or patting the upper back is the most appropriate first action. This position helps bring up any air swallowed during feeding, reducing the likelihood of spitting up. Gently rubbing or patting the back encourages the burp reflex.

Additional Notes:

• After burping the baby, the nurse can assess the amount of spit-up and clean the baby and surrounding area as needed.
• If the baby shows signs of respiratory distress after burping, suctioning may be necessary. However, this should only be done by a healthcare professional.
• If the spitting up is frequent or forceful, the nurse should consult with a doctor to rule out any underlying medical conditions.

Choice A rationale

While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.

Choice B rationale

Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.

Choice C rationale

Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.

Choice D rationale

Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.

Choice A rationale

Avoiding caffeinated drinks for 24 hours before conducting the kick test is not necessary. Caffeine does not significantly affect fetal movements.

Choice B rationale

Exercising for 15 minutes before starting the counting to help increase fetal movement is not a standard recommendation. While physical activity can sometimes stimulate fetal movement, it’s not a requirement for performing kick counts.

Choice C rationale

Counting the movements once daily, for one hour, before breakfast is not the standard recommendation. The best time to do kick counts is when the baby is usually most active, which might be after a meal, early in the morning, or at another point in the day.

Choice D rationale

If 10 kicks are not felt within one hour, drinking orange juice and counting for another hour is a common recommendation. The sugar in the juice can sometimes stimulate the baby to move. However, if the mother still doesn’t feel 10 movements within 2 hours, she should contact her healthcare provider.

Choice A rationale

While monitoring the client’s vital signs is an important part of postpartum care, it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice B rationale

Notifying the healthcare provider is important, but it would not be the first action to take. The nurse should first attempt to address the issue.

Choice C rationale

Inspecting the perineal pad could provide information about the client’s postpartum bleeding, but it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice D rationale

Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.

Choice A rationale

Covering the lesion with a dressing is not the standard care for a pregnant client with active herpes lesions. Herpes can be transmitted to the baby during a vaginal birth, even if lesions are covered.

Choice B rationale

Preparing for a cesarean section is the correct action. A cesarean section is often recommended for women with active genital herpes lesions to prevent transmission of the virus to the baby during delivery.

Choice C rationale

Obtaining blood cultures is not typically necessary for a client with active herpes lesions. Herpes is a viral infection, and its presence is usually determined through a visual examination of lesions and sometimes a swab of the lesion, not through blood cultures.

Choice D rationale

Administering penicillin is not the correct action. Penicillin is an antibiotic, which is used to treat bacterial infections, not viral infections like herpes.