Choice A reason:
Initiating epidural anesthesia too soon may delay rupture of fetal membranes. This statement is not accurate. Epidural anesthesia itself does not have a direct impact on the rupture of fetal membranes. The timing of rupturing membranes is determined based on the progress of labor and other clinical indications. There is no causal relationship between epidural anesthesia and the timing of membrane rupture.

Choice B reason:
Initiating epidural anesthesia too soon can prolong labor. This statement is correct. Epidural anesthesia, while providing pain relief during labor, can also cause some degree of motor blockage and decrease the woman's ability to push effectively. This can potentially lead to a lengthening of the labor process. It is generally recommended to wait until a good labor pattern has been established to avoid unnecessary prolongation of labor.

Choice C reason:
Initiating epidural anesthesia too soon can cause fetal depression. This statement is not entirely accurate. Epidural anesthesia can cross the placenta and reach the fetus, but the effect on the baby is usually minimal. However, fetal monitoring is essential during labor to ensure the baby's well-being, regardless of whether epidural anesthesia is used or not.

Choice D reason:
Initiating epidural anesthesia too soon can cause maternal hypertension. This statement is not supported by evidence. Epidural anesthesia does not typically cause maternal hypertension. It can, however, lead to a decrease in blood pressure in some cases, which is why careful monitoring of maternal blood pressure is necessary during and after the administration of epidural anesthesia.

Choice A:
During the immediate postpartum period, shaking chills can be indicative of an infection or fever. Therefore, the nurse should first assess the client's temperature to identify if there is a fever. This information is crucial for making appropriate clinical decisions and providing necessary interventions.
Choice B:
The reason for not selecting B, and placing the client on seizure precautions, is that shaking chills alone do not necessarily indicate a seizure. Seizure precautions are typically implemented for clients with a history of seizures or those at risk for seizures due to neurological conditions. In this scenario, focusing on the client's temperature is more relevant to address the immediate concern.
Choice C:
The reason for not choosing C, notifying the charge nurse, is that this action might not directly address the client's condition. While involving the charge nurse can be essential for certain situations, it is not the primary intervention required for a client experiencing shaking chills. The nurse should first assess the client and initiate appropriate actions based on their assessment.
Choice D:
The reason for not selecting D, covering the client with warm blankets, is that shaking chills are often associated with fever, which indicates the body is trying to raise its temperature. Providing warm blankets may exacerbate the fever and is not the appropriate initial action. Determining the client's temperature is necessary to guide further interventions effectively.

Choice A rationale:

The correct answer is choice A. The nurse should respond, "We have a neonatal unit here equipped to handle emergencies.”. The rationale behind this response is that it provides reassurance to the client while addressing her concerns about the well-being of her baby. By mentioning the presence of a neonatal unit, the nurse indicates that there are resources available to handle any potential complications or emergencies that may arise during labor or after delivery. This response helps to alleviate the client's anxiety and demonstrates that the hospital is well-prepared to provide appropriate care for both the mother and the baby.

Choice B rationale:

The reason for not selecting choice B is that it does not directly address the client's question about her baby's well-being. While acknowledging the client's emotions is important, responding solely with empathy and stating that she must be feeling scared may not sufficiently address her concerns or provide the necessary information.

Choice C rationale:

The reason for not choosing choice C is that it may be interpreted as minimizing the client's worries. While it is true that many expectant mothers experience anxiety during labor, this response may not be reassuring to the client in this specific situation. It could potentially downplay her feelings and not provide the support she needs.

Choice D rationale:

The reason for not selecting choice D is that it offers a blanket reassurance without addressing the client's specific condition or concerns. While being at 32 weeks of gestation is generally considered to be a safe point in pregnancy, every case is unique, and complications can still occur. The nurse's response should acknowledge the client's concerns and provide more specific information about the hospital's capabilities to handle potential issues.

Choice A rationale:
Fetal head compression is unlikely to cause variable decelerations in the fetal heart rate. During contractions and labor, the fetal head may experience pressure, but this usually leads to early decelerations, not variable decelerations. Early decelerations are considered benign and are caused by the head's pressure stimulating the vagus nerve, resulting in a temporary decrease in heart rate.
Choice B rationale:
Umbilical cord compression is a known cause of variable decelerations in the fetal heart rate. When the umbilical cord is compressed, it can temporarily disrupt blood flow and oxygen supply to the fetus, leading to decelerations. Variable decelerations often appear as abrupt, sharp drops in the fetal heart rate and are typically characterized by their unpredictable
nature.
Choice C rationale:
Maternal opioid administration is not a direct cause of variable decelerations in the fetal heart rate. While opioids can cross the placenta and may affect the fetus, they are more likely to cause other issues, such as respiratory depression in the newborn, rather than variable decelerations.
Choice D rationale:
Uteroplacental insufficiency is not the primary factor causing variable decelerations. Uteroplacental insufficiency refers to an inadequate blood flow and oxygen delivery to the placenta, which can lead to late decelerations in the fetal heart rate, not variable decelerations.

Choice A rationale:

Fetal head compression is unlikely to cause variable decelerations in the fetal heart rate. During contractions and labor, the fetal head may experience pressure, but this usually leads to early decelerations, not variable decelerations. Early decelerations are considered benign and are caused by the head's pressure stimulating the vagus nerve, resulting in a temporary decrease in heart rate.

Choice B rationale:

Umbilical cord compression is a known cause of variable decelerations in the fetal heart rate. When the umbilical cord is compressed, it can temporarily disrupt blood flow and oxygen supply to the fetus, leading to decelerations. Variable decelerations often appear as abrupt, sharp drops in the fetal heart rate and are typically characterized by their unpredictable

nature.

Choice C rationale:

Maternal opioid administration is not a direct cause of variable decelerations in the fetal heart rate. While opioids can cross the placenta and may affect the fetus, they are more likely to cause other issues, such as respiratory depression in the newborn, rather than variable decelerations.

Choice D rationale:

Uteroplacental insufficiency is not the primary factor causing variable decelerations. Uteroplacental insufficiency refers to an inadequate blood flow and oxygen delivery to the placenta, which c

Choice A rationale:

Excessive uterine enlargement. Rationale: The nurse should monitor the client for excessive uterine enlargement, as a hydatidiform mole is a rare condition in pregnancy where abnormal placental tissue forms instead of a fetus. This abnormal growth can lead to uterine enlargement beyond the expected size for gestational age.

Choice B rationale:

Rapidly dropping human chorionic gonadotropin (hCG) levels. Rationale: The nurse should also monitor the client's hCG levels. In a normal pregnancy, hCG levels typically rise steadily during the early stages. However, in the case of a hydatidiform mole, hCG levels may either plateau or drop rapidly due to the abnormal placental growth.

Choice C rationale:

Fetal heart rate irregularities. Rationale: Although a hydatidiform mole does not involve a viable fetus, the nurse should still assess for fetal heart rate irregularities. In some rare cases, the presence of abnormal placental tissue can cause confusion in the diagnosis, and there may be coexisting fetal development. Fetal heart rate irregularities may indicate potential complications.

Choice D rationale:

Whitish vaginal discharge. Rationale: Whitish vaginal discharge is not typically associated with a hydatidiform mole. Instead, this finding is more commonly seen in other vaginal infections or conditions unrelated to a molar pregnancy. The nurse should be cautious not to misinterpret this symptom as a definitive sign of a hydatidiform mole.

Choice A rationale:

This statement is incorrect because Rho(D) immune globulin does not destroy Rh antibodies in a newborn who is Rh-positive. Instead, it acts to prevent the development of Rh antibodies in the mother.

Choice B rationale:

This statement is also incorrect. Rho(D) immune globulin does not destroy Rh antibodies in a woman who is Rh-negative. It is given to Rh-negative women to prevent them from forming Rh antibodies in response to Rh-positive fetal blood during pregnancy.

Choice C rationale:

This is the correct choice. Rho(D) immune globulin is given to Rh-negative women to prevent the formation of Rh antibodies. If an Rh-negative woman is exposed to Rh-positive blood (usually during childbirth), her immune system may recognize the Rh antigen as foreign and start producing Rh antibodies. These antibodies could potentially cross the placenta during a subsequent pregnancy and attack the red blood cells of an Rh-positive fetus, causing hemolytic disease in the newborn. Rho(D) immune globulin helps prevent this sensitization process.

Choice D rationale:

This statement is incorrect. Rho(D) immune globulin does not prevent the formation of Rh antibodies in a newborn who is Rh-positive. Its main purpose is to protect Rh-negative women from forming antibodies that could harm future Rh-positive pregnancies.

Choice A rationale:

Preparing the client for an emergency cesarean birth might be necessary if there's a prolapsed cord, but it's not the first action to take. The nurse needs to stabilize the situation and protect the cord before considering any other interventions.

Choice B rationale:

While explaining to the client what is happening is essential for informed consent and to reduce anxiety, it is not the first priority when the umbilical cord is protruding. Immediate action to protect the cord and the baby is necessary.

Choice C rationale:

Covering the cord with a sterile, moist saline dressing is the first and most crucial step to take. This helps to prevent the cord from drying out and reduces the risk of infection. The nurse should gently push the presenting part of the baby off the cord and cover it with a sterile, moist dressing.

Choice D rationale:

Placing the client in a knee-chest or Trendelenburg position might be indicated in some cases of cord prolapse, but it is not the first action to take. Covering the cord takes precedence to protect the baby's oxygen supply.

Choice D rationale:

The nurse should state, "The purpose of this medication is to boost fetal lung maturity.”. The rationale behind this choice is that betamethasone is a corticosteroid medication commonly administered to women at risk of preterm delivery between 24 and 34 weeks of gestation. Its primary goal is to accelerate fetal lung maturation by promoting the production of surfactant, a substance that coats the lungs and prevents their collapse. By enhancing lung development, the medication helps reduce the risk of respiratory distress syndrome and other respiratory complications that premature infants might face. It does not directly impact fetal heart rate (Choice A), halt cervical dilation (Choice B), or stop preterm labor contractions (Choice C).

Choice A rationale:

The nurse should not state, "The purpose of this medication is to increase the fetal heart rate.”. Betamethasone does not affect the fetal heart rate, as it is primarily used to enhance lung maturity, as mentioned earlier. The incorrect statement may lead to confusion and misunderstanding of the medication's intended purpose.

Choice B rationale:

The nurse should not state, "The purpose of this medication is to halt cervical dilation.”. Betamethasone does not stop or halt cervical dilation. Its main action is on the fetal lungs to promote surfactant production. Cervical dilation is a natural process that occurs during labor and is not influenced by this medication.

Choice C rationale:

The nurse should not state, "The purpose of this medication is to stop preterm labor contractions.”. Betamethasone is not used to stop or prevent preterm labor contractions directly. Instead, its focus is on improving fetal lung maturity to enhance the baby's respiratory function once born prematurely.

Choice A rationale:

Choice A, fetal head compression, is not the correct answer in this case. Fetal head compression can cause early decelerations in the FHR, not variable decelerations. Early decelerations are often a result of the fetal head being compressed during contractions and are considered benign and expected during labor.

Choice B rationale:

The correct answer is choice B, which is umbilical cord compression. Variable decelerations of the fetal heart rate (FHR) can occur during labor due to various rationales, and umbilical cord compression is one of the common causes. When the umbilical cord gets compressed, it can briefly reduce or restrict the blood flow and oxygen supply to the fetus, leading to temporary decelerations in the FHR.

Choice C rationale:

Choice C, maternal fever, is also not the correct answer for variable decelerations in FHR. Maternal fever can be a sign of infection, and it may lead to other fetal heart rate abnormalities, such as tachycardia (an increased heart rate), but it is not specifically associated with variable decelerations.

Choice D rationale:

Choice D, polyhydramnios, is not the cause of variable decelerations in this scenario. Polyhydramnios refers to an excessive accumulation of amniotic fluid around the fetus. While it can have implications for pregnancy, it is not directly linked to variable decelerations of the FHR.

Choice A rationale:
0.25 mL - The nurse should not administer 0.25 mL because the available concentration of vitamin K injection is 1 mg/0.5 mL. To achieve the prescribed dose of 1 mg, administering only 0.25 mL would be insufficient.
Choice B rationale:
0.5 mL - This is the correct choice. The nurse should administer 0.5 mL of the vitamin K injection to deliver 1 mg of vitamin K, as the concentration of the injection is 1 mg/0.5 mL. By giving the full 0.5 mL, the newborn will receive the appropriate 1 mg dose.
Choice C rationale:
0.75 mL - Administering 0.75 mL would be excessive for the prescribed 1 mg dose of vitamin K. It is unnecessary to give a higher volume than required, as it could lead to potential adverse effects or wastage.
Choice D rationale:
1 mL - Similarly, administering the entire 1 mL of the vitamin K injection would result in doubling the prescribed dose, leading to potential overdose and adverse reactions. The nurse should avoid administering more than the necessary 0.5 mL.

Choice A rationale:

The nurse should not inject vitamin K IM into the deltoid muscle. The deltoid muscle is located in the upper arm and is not recommended for IM injections in newborns due to its small size and proximity to the brachial plexus, which could potentially cause nerve damage or injury.

Choice B rationale:

The nurse should not inject vitamin K IM into the dorsogluteal muscle. The dorsogluteal muscle is located in the buttocks and is not recommended for IM injections in newborns because it is difficult to accurately locate and has a higher risk of hitting the sciatic nerve or the superior gluteal artery.

Choice C rationale:

The nurse should administer vitamin K IM into the ventrogluteal muscle. This site is considered the preferred site for IM injections in newborns. It is located on the lateral aspect of the hip, away from major nerves and blood vessels, reducing the risk of complications. Additionally, the ventrogluteal muscle has a thicker muscle mass, making it suitable for the administration of medications.

Choice D rationale:

The nurse should not inject vitamin K IM into the vastus lateralis muscle. While the vastus lateralis muscle, located in the thigh, is often used for IM injections in infants, the ventrogluteal site is preferred because it provides a larger muscle mass and is further away from important structures, reducing the risk of injury.

Choice C rationale:

This response is correct because black stools are a common side effect of taking iron supplements. Iron can cause the stool to appear black or

tarry due to the way it is broken down during digestion. It does not necessarily indicate a serious issue, especially if the client is not experiencing any abdominal pain or cramping. Educating the client about this expected side effect helps alleviate any concerns they might have about the change in stool colour.

Choice A rationale:

"Go to the emergency room and your provider will meet you there.”. This response is not appropriate in this situation. The client's report of black stools without abdominal pain or cramping is likely due to the iron supplements and does not warrant a visit to the emergency room. This response may cause unnecessary panic and anxiety for the client.

Choice B rationale:

"What else have you been eating?.”. This response is also not the best choice. While it's essential for healthcare providers to gather comprehensive information about a client's diet and lifestyle, in this case, the client's black stools can be directly attributed to the iron supplements. Focusing on other dietary factors might distract from addressing the client's concern about the side effect of iron supplementation.

Choice D rationale:

"Come to the office, and we will check things out.”. This response is not the most appropriate one either. A visit to the office might not be necessary solely based on the client's report of black stools without accompanying pain or cramping. This situation can be managed through education, and the client can be reassured that it is a typical side effect of iron supplements. An unnecessary visit to the office could inconvenience the client and waste both their time and the healthcare provider's time.

Choice A rationale:

Placing a soft pillow under the client's buttocks (Choice A) might provide some comfort, but it won't directly address the unrelieved episiotomy pain. The pillow is more commonly used for providing support and pressure relief in cases like haemorrhoids or after rectal surgeries.

Choice B rationale:

Applying an ice pack to the perineum (Choice B) could help reduce swelling and inflammation, which might be beneficial in the immediate postpartum period. However, since the client's pain is unrelieved after 8 hours, it suggests the need for additional measures beyond cold therapy.

Choice C rationale:

Positioning a heating lamp toward the episiotomy (Choice C) is not recommended. Heat can exacerbate inflammation and may increase pain in the perineal area. This approach is generally not used for managing postpartum pain or episiotomy discomfort.

Choice D rationale:

Preparing a warm sitz bath (Choice D) is the most appropriate action for the nurse to take in this situation. A warm sitz bath can promote healing and provide relief from episiotomy pain by promoting blood flow to the area, reducing muscle tension, and soothing the tissues. It is a widely accepted and effective intervention for postpartum perineal discomfort.

Choice A rationale:
Maternal hypertension is a potential risk factor for other pregnancy complications, such as preeclampsia or gestational hypertension. However, it is not the most common risk factor for placental abruption. Placental abruption occurs when the placenta separates from the uterine wall before delivery, and its primary risk factors are different.

Choice B rationale:
Maternal cocaine use is the most common risk factor for placental abruption. Cocaine is a potent vasoconstrictor, meaning it narrows blood vessels, which can lead to reduced blood flow to the placenta. The decreased blood flow can cause the placenta to detach, resulting in placental abruption. This poses significant risks to both the mother and the baby.

Choice C rationale:
Maternal cigarette smoking is associated with various adverse pregnancy outcomes, including low birth weight, preterm birth, and sudden infant death syndrome (SIDS). While smoking can negatively impact the placenta, it is not the most common risk factor for placental abruption.

Choice D rationale:
Maternal battering, or domestic violence, can have severe consequences for the pregnant woman and the developing fetus. However, it is not the most common risk factor for placental abruption. Placental abruption is more closely linked to substance abuse, like cocaine use, as previously explained.

Choice A rationale:

Supporting the infant during birth. The priority for the nurse in this situation is to ensure the safe delivery of the baby. By supporting the infant during birth, the nurse can help ensure that the baby is delivered safely and efficiently. This involves assisting the mother in pushing and guiding the baby's head and body as it emerges from the birth canal. The nurse should also be ready to catch the baby and provide immediate care, such as drying and stimulating the baby to breathe if necessary.

Choice B rationale

Preventing the perineum from tearing. While preventing perineal tearing is important, it is not the top priority in this rapidly progressing labor scenario. The immediate concern is the safe delivery of the baby, and if perineal tearing does occur, it can be addressed after the birth.

Choice C rationale

Cutting the umbilical cord. This action is necessary but not the top priority. After the baby is delivered, the nurse should clamp and cut the umbilical cord to separate the baby from the placenta. However, this can wait until the baby is fully delivered and breathing on their own.

Choice D rationale

Promoting delivery of the placenta. Again, while delivering the placenta is important to prevent postpartum haemorrhage, it is not the priority in this scenario. The nurse's immediate focus should be on supporting the infant's delivery and ensuring the baby's well-being.

Choice A rationale:

Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labour, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.

Choice B rationale:

Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.

Choice C rationale:

Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labour has commenced. Panting is not necessary at this point.

Choice D rationale:

The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.

Choice A rationale:

Visual disturbances should be reported to the provider because the client is experiencing headaches, blurred vision, and dizziness, which can be signs of preeclampsia. Preeclampsia is a serious condition that can develop during pregnancy and is characterized by high blood pressure and damage to organs like the liver and kidneys. Visual disturbances may indicate neurological involvement and can pose a risk to both the client and the fetus.

Choice B rationale:

Blood pressure should be reported to the provider due to the client's symptoms and medical history. The client's weight gain, swelling of feet and fingers, and 2+ pitting edema suggest fluid retention, which can be associated with preeclampsia. High blood pressure is a key diagnostic criterion for preeclampsia, and the nurse must monitor it closely to assess the severity of the condition and the potential risk to both the client and the fetus.

Choice C rationale:

Respirations do not appear to be a significant concern based on the information provided. While respiratory status is important to monitor during pregnancy, there are no indications in the scenario to suggest respiratory distress or abnormalities that require immediate reporting to the provider.

Choice D rationale:

Deep tendon reflexes are mentioned in the client's medical history but do not show any immediate signs of concern. Absent clonus and 3+ deep tendon reflexes are within the normal range and not typically alarming during pregnancy. However, the nurse should continue to monitor these reflexes during subsequent visits.

Choice E rationale:

Weight gain is mentioned in the medical history but is not currently a critical finding to report. A 6 lb weight gain over 2 weeks may be considered appropriate for a pregnant client at 32 weeks of gestation, but it should be assessed in conjunction with other symptoms for a comprehensive evaluation.

Choice A rationale:

The client's statement, "I need to schedule the test when the baby is usually active,”. is accurate and demonstrates a good understanding of the nonstress test (NST). The NST is typically performed to assess the baby's heart rate and movements when they are active, which provides better insights into the baby's well-being.

Choice B rationale:

The client's statement, "The baby's heart rate will be monitored during the test,”. is correct and indicates a solid grasp of the purpose of the NST. During the test, the baby's heart rate is continuously monitored to assess their overall well-being and any signs of distress.

Choice C rationale:

This is the correct answer. The client's statement, "I will have to lie on my back during the test,”. indicates a need for further teaching. In an NST, pregnant individuals are usually asked to lie on their left side, not on their back. The left lateral position enhances blood flow to the placenta and the baby, making it the preferred position for this test.

Choice D rationale:

The client's statement, "I will be able to go to the bathroom during the test as necessary,”. is accurate and demonstrates a good understanding of the NST procedure. Unlike some other prenatal tests, NST allows pregnant individuals to change positions, including using the bathroom if needed, to ensure their comfort during the monitoring process.

Choice B rationale:

The client's complaint of feeling lightheaded and experiencing tingling fingers indicates hyperventilation, which can occur with pattern-paced breathing during labor. Administering oxygen via nasal cannula helps to address the respiratory alkalosis that may result from excessive breathing. The additional oxygen can help correct the imbalanced levels of carbon dioxide and oxygen in the blood, alleviating the symptoms of lightheadedness and tingling.

Choice A rationale:

Instruct the client to maintain a breathing rate no less than twice the normal rate. Rationale: Instructing the client to breathe at a rate no less than twice the normal rate may worsen hyperventilation. This will further decrease the level of carbon dioxide in the blood, exacerbating respiratory alkalosis and its associated symptoms. Therefore, this option is not appropriate and should be avoided.

Choice C rationale

Assist the client to breathe into a paper bag. Rationale: Breathing into a paper bag is a common intervention used to treat hyperventilation. However, it is not suitable for a pregnant woman in labor. It is essential for the mother to have an adequate intake of oxygen during labor to support both her and the baby's needs. Breathing into a paper bag would prevent her from getting enough oxygen and could potentially harm both her and the baby.

Choice D rationale

Have the client tuck her chin to her chest. Rationale: Tucking the client's chin to her chest is not a relevant action to address hyperventilation. This maneuver is commonly used during the second stage of labor to promote fetal descent and prevent cervical lacerations. However, it is not useful in managing the client's current symptoms of lightheadedness and tingling fingers resulting from hyperventilation.

Choice A rationale:

Confirm identification and apply a bracelet. The first action the nurse should take is to confirm the identification of the newborn and apply a bracelet. This is crucial to ensure the correct identification of the baby and prevent any mix-ups. The bracelet will typically have the newborn's name, birthdate, and other identifying information. By doing this promptly, the nurse can establish a proper record-keeping system and maintain the safety and security of the newborn within the healthcare facility.

Choice B rationale

Examine the newborn for birth defects. Although examining the newborn for birth defects is important, it is not the first action the nurse should take immediately after delivery. The immediate well-being and safety of the newborn take priority over a comprehensive examination for birth defects. The nurse can perform a thorough examination later, but right after delivery, other critical tasks must be addressed first.

Choice C rationale

Dry the newborn. Drying the newborn is also an essential step, but it can wait a moment. The newborn's skin should be dried to prevent heat loss and promote bonding with the parents. However, the first action should be something more critical to the immediate health and safety of the baby.

Choice D rationale

Conduct a gestational age assessment. Assessing the gestational age of the newborn is important for appropriate care planning, but it is not the first action the nurse should take immediately after delivery. This assessment can be done shortly after the initial steps have been taken to ensure the baby's immediate well-being.

Choice A rationale:

Rh incompatibility is not relevant in this scenario. Rh incompatibility refers to a condition where the mother's blood is Rh-negative, and the baby's blood is Rh-positive, which can lead to hemolytic disease of the newborn. However, this condition is unrelated to the client's current presentation of heavy, red vaginal bleeding without contractions.

Choice B rationale:

Frequency and duration of contractions are not the primary concern in this situation. The client's main complaint is heavy vaginal bleeding without contractions, which indicates a potential issue with the placenta or other pregnancy-related problems.

Choice C rationale:

Fetal lung maturity is not the priority at this stage. The client is at 38 weeks of gestation, which is considered full term. Fetal lung maturity is typically assessed if there's a need for early delivery, which is not indicated in this scenario.

Choice D rationale:

The correct choice. The client is experiencing heavy, red vaginal bleeding, which may be a sign of placental abruption, where the placenta separates from the uterine wall prematurely. Determining the location of the placenta through an ultrasound can help identify if placental abruption is the cause of bleeding. Placental abruption can be a serious condition that requires immediate medical attention.

Choice A rationale:

The nurse should schedule a 3-hour oral glucose tolerance test (OGTT) for the client because the blood glucose levels taken 1 hour following a meal are higher than the expected range for gestational diabetes. This test will help to diagnose and assess the client's glucose tolerance and determine if there is gestational diabetes or any other potential glucose regulation issues.

Choice B rationale:

Increasing carbohydrates to 65% of daily nutritional intake is not the appropriate action in this situation. It may lead to further elevation of blood glucose levels, which can be detrimental for a client with gestational diabetes. The goal is to manage blood glucose levels and prevent complications, so recommending a higher carbohydrate intake would be counterproductive.

Choice C rationale:

Obtaining an HbA1c (glycated hemoglobin) is not the most suitable action in this scenario. HbA1c provides an average of the blood glucose levels over the past few months, which is more helpful for diagnosing and monitoring chronic diabetes, rather than gestational diabetes, which is temporary and occurs during pregnancy. An OGTT is a more appropriate test for gestational diabetes assessment.

Choice D rationale:

Reinforcing instruction about insulin administration is not warranted at this point since there is no information indicating that the client is currently on insulin therapy. Additionally, using insulin as the first step in the management of gestational diabetes is not common practice. Lifestyle modifications, dietary changes, and other measures are usually attempted first.

Choice A rationale:
Severe nausea and vomiting are not indicative of an ectopic pregnancy. While nausea and vomiting are common symptoms in early pregnancy, they are not specific to ectopic pregnancies. These symptoms are more likely associated with typical pregnancy changes.

Choice B rationale:
Pelvic pain is a crucial finding that the nurse should expect in a possible ectopic pregnancy. As the pregnancy implants outside of the uterus, usually in the fallopian tube, it can cause sharp and severe pain in the pelvic region. This pain may be unilateral and can be accompanied by shoulder pain due to blood or fluid irritating the diaphragm.

Choice C rationale:
Uterine enlargement greater than expected for gestational age is not likely in an ectopic pregnancy. In fact, uterine enlargement may not be noticeable at all in an ectopic pregnancy since the embryo is not developing in the uterus.

Choice D rationale:
Copious vaginal bleeding is more commonly associated with miscarriages or other complications in intrauterine pregnancies. In an ectopic pregnancy, vaginal bleeding may occur, but it is typically lighter and often described as spotting.

Choice A rationale :

The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse respiratory depression and prevent further complications.

Choice B rationale

Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.

Choice C rationale

Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.

Choice D rationale

Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.