A client’s prenatal laboratory findings reveal no immunity to rubella.
The health care provider orders the rubella vaccine.
The nurse concludes that teaching about this medication is effective when the client states which of the following?

Choice A rationale

Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.

Choice B rationale

Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.

Choice C rationale

Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.

Choice D rationale

Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.

Choice A rationale

If a client reports feeling “down” and sad, having no energy, and wanting to cry, these could be signs of postpartum depression. It’s crucial to assess whether the client has considered harming her newborn, as this could indicate a severe form of postpartum depression that requires immediate intervention.

Choice B rationale

While anticipating a prescription for an antidepressant might be part of the treatment plan for postpartum depression, it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

Choice C rationale

Assisting the family to identify prior use of positive coping skills in family crises could be helpful, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

Choice D rationale

Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.