Description

Which action is most important for the nurse to implement for a client at 36- weeks gestation who is admitted with vaginal bleeding? Monitor uterine contractions. Apply disposable pads under the client. Determine fetal heart rate and maternal vital signs. Obtain blood samples for hemoglobin hematocrit levels. Rationale The priority nursing action is assessment of the fetal heart rate and maternal vital signs (C) to evaluate the impact of blood loss in the mother and fetus. Although monitoring uterine activity (A), applying pads to assess bleeding amount (B), and obtaining samples for hemoglobin and hematocrit levels (D) should be implemented, these are not as important as assessing maternal and fetal wellbeing. Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor? Brighten the lighting so the mother can view the infant. Complete the newborn assessment as quickly as possible. Provide positive reinforcement for maternal care of infant. Encourage early initiation of breast or formula feeding. Rationale (D) is the best of the interventions listed to encourage maternal-infant bonding. (A, B, and C) are all methods of promoting maternal-infant bonding but are not usually as effective as initiating infant feeding. A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action? Assess newborn reflexes for signs of neurological impairment. Leave the infant in the room with the mother to foster attachment. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. Perform a gestational age assessment to determine if the infant is large-for-gestationalage. Rationale The infant's birth weight falls within the parameter (4000 grams or greater) for a large-for-gestational-age (LGA) infant and should be assessed for hypoglycemia (C) and trauma. Early recognition of hypoglycemia requires immediate intervention and takes precedence over assessing newborn reflexes (A). Although the infant may remain in the room with the mother (B), frequent assessments of the newborn should be performed. Additional assessment tools (D) can be used after serum glucose levels are determined