🤰 Tetracycline is contraindicated during pregnancy because it crosses the placenta and can harm fetal development.

🤰 Exposure may cause permanent discoloration of fetal teeth, impaired bone growth, and effects on skeletal development.

🤰 Tetracyclines are generally avoided during pregnancy, especially during the second and third trimesters due to fetal risks.

🤰 In a pregnant client with syphilis, the recommended treatment is penicillin therapy, as it effectively treats both the mother and helps prevent congenital syphilis.

🤰 Nurses should reinforce completing treatment and ensuring follow-up testing.

❌ Ceftriaxone

❌ Ceftriaxone is not the contraindicated medication in pregnancy in this scenario.

❌ It may be used for selected infections under provider guidance.

❌ Benzathine penicillin G

❌ Benzathine penicillin G is the treatment of choice for syphilis during pregnancy.

❌ It is the preferred therapy to reduce fetal transmission.

❌ Azithromycin

❌ Azithromycin is not the standard treatment for syphilis in pregnancy but is not the contraindicated option here.

❌ Penicillin remains preferred.

👶 Immediately after birth, newborn identification is a high-priority safety intervention to prevent infant misidentification and ensure correct matching with the parent.

👶 The nurse should apply two identification bands to the newborn’s extremities (commonly the wrist and ankle) according to facility policy.

👶 Identification bands are applied as soon as possible after birth and before separation from the parent.

👶 The information on the bands must match the mother’s identification information to ensure safe care and newborn security.

👶 Nurses should verify identification during assessments, procedures, feedings, and transport.

❌ Footprint the newborn prior to applying an identification band.

❌ Footprints may be obtained according to facility policy but are not completed before immediate identification procedures.

❌ Identification bands are applied first to establish identity promptly.

❌ Transport the newborn to the nursery to apply the identification band.

❌ Identification should occur in the birthing area before transport or separation from the parent.

❌ Delaying identification increases risk of newborn identification errors.

❌ Check that the identification band label includes the newborn's weight.

❌ Identification bands generally focus on matching identifiers rather than newborn weight.

❌ Weight is documented in the health record but is not the key identification element.

🤰 A prepregnancy BMI of 21 falls within the normal BMI range (18.5–24.9).

🤰 For clients with a normal BMI before pregnancy, the recommended total pregnancy weight gain is 11.4 to 15.9 kg (25 to 35 lb).

🤰 Appropriate weight gain supports normal fetal growth, placental development, maternal nutritional needs, and healthy pregnancy outcomes.

🤰 Insufficient weight gain may increase the risk of fetal growth restriction and low birth weight, while excessive gain may increase the risk of gestational hypertension, gestational diabetes, and delivery complications.

🤰 Weight gain should occur gradually, with increased nutritional intake focused on balanced nutrition rather than excess calories.

❌ 16.4 to 20.5 kg (36 to 45 lb)

❌ This range is generally recommended for clients who are underweight before pregnancy (BMI <18.5).

❌ A BMI of 21 does not require this amount of gain.

❌ 8.2 to 10.9 kg (18 to 24 lb)

❌ This amount is lower than recommended for a normal prepregnancy BMI.

❌ Such ranges are more consistent with overweight pregnancy recommendations.

❌ 5 to 7.7 kg (11 to 17 lb)

❌ This lower weight gain recommendation is typically associated with obesity in pregnancy.

❌ It would not be appropriate for a client with BMI 21.

🍼 FHR

🍼 The fetal heart rate (FHR) is the most important indicator of fetal oxygenation during labor.

🍼 This client is showing late decelerations, where the FHR drops after the contraction begins and returns to baseline after the contraction ends.

🍼 Late decelerations suggest uteroplacental insufficiency, meaning the fetus may not be receiving enough oxygen during contractions.

🍼 The baseline returns to 150/min, but repeated drops to 103–108/min are concerning and require close monitoring.

🍼 Continued FHR monitoring helps detect worsening fetal distress, prolonged decelerations, or need for urgent intervention.

🍼 Contraction pattern

🍼 The nurse should monitor the frequency, duration, and uterine resting tone of contractions because abnormal contractions can reduce fetal oxygenation.

🍼 This client’s contractions are occurring every 5 to 6 minutes and lasting 55 to 60 seconds, with uterine tone described as firm.

🍼 If contractions become too frequent, too long, or the uterus does not relax well between contractions, fetal oxygen exchange can decrease.

🍼 Adequate uterine relaxation between contractions allows blood flow to return through the placenta.

🍼 Monitoring the contraction pattern helps determine whether uterine activity is contributing to the late decelerations.

🍼 Amniotic fluid characteristics

🍼 The amniotic fluid changed from clear fluid to thin green fluid, which indicates meconium-stained amniotic fluid.

🍼 Meconium may occur when the fetus experiences stress or hypoxia before or during labor.

🍼 Green fluid increases concern for possible fetal compromise and risk for meconium aspiration after birth.

🍼 The nurse should continue assessing the amount, color, odor, and consistency of the fluid.

🍼 Changes in amniotic fluid provide important clues about fetal well-being and possible labor complications.

❌ Blood pressure

❌ The client’s blood pressure remains stable, ranging from 124/72 to 128/74 mm Hg, so it is not the main indicator of the current complication.

❌ Blood pressure should still be monitored routinely, but the urgent concerns are fetal status, uterine activity, and fluid changes.

❌ Pain level

❌ The pain level increased only from 4/10 to 5/10, which is expected as labor progresses.

❌ Pain does not explain the late decelerations or green amniotic fluid.

❌ Oxygen saturation

❌ The client’s oxygen saturation remains acceptable at 95–98% on room air.

❌ Maternal oxygenation should be monitored, but fetal tracing and meconium-stained fluid are more directly related to the complication.

❌ IV site

❌ The IV site is important for fluid and medication access, but it does not identify the current fetal labor complication.

❌ No signs of IV infiltration or malfunction are provided.

❌ Cervical dilation

❌ Cervical dilation helps assess labor progress, but it does not directly explain late decelerations or meconium-stained fluid.

❌ The priority is fetal response to labor and possible fetal compromise.

✅ Insert a straight catheter for the client

🩸 The deviated, elevated fundus strongly suggests bladder distention, preventing the uterus from contracting effectively.

🩸 The client cannot ambulate because of residual epidural numbness, making spontaneous voiding difficult.

🩸 Emptying the bladder allows the uterus to move back to midline and contract more effectively.

🩸 Improved uterine contraction decreases postpartum bleeding.

🩸 Catheterization is an immediate nursing priority.

✅ Administer methylergonovine 0.2 mg IM

🩸 Methylergonovine is a uterotonic that stimulates strong uterine contractions to control postpartum bleeding.

🩸 Since fundal massage failed and oxytocin infusion has already completed, an additional uterotonic is indicated.

🩸 This client’s BP is low, so hypertension is not a contraindication.

🩸 Increased uterine tone helps compress blood vessels and reduce hemorrhage.

🩸 Continuous monitoring of bleeding and uterine firmness is required.

❌ Draw a complete blood count

❌ CBC may be needed later to evaluate blood loss, but it does not stop active hemorrhage.

❌ Immediate stabilization and bleeding control take priority.

❌ Weigh the client’s perineal pad

❌ Blood loss is already quantified (980 mL) and active hemorrhage is evident.

❌ Treatment should not be delayed for additional measurement.

❌ Apply O₂ per nonrebreather mask

❌ Oxygen may become necessary if oxygenation worsens, but the current SpO₂ is 98%.

❌ Correcting the bleeding source is the immediate priority.

🤰 Chadwick sign is a probable sign of pregnancy and refers to the bluish-purple discoloration of the cervix, vagina, and vulva caused by increased vascularity and blood flow during pregnancy.

🤰 Probable signs are objective findings observed by the examiner and strongly suggest pregnancy, but they are not absolutely diagnostic.

🤰 Chadwick sign usually appears during the early weeks of pregnancy and is identified during pelvic examination.

🤰 Other probable signs include Goodell sign, Hegar sign, positive pregnancy test, uterine enlargement, and Braxton Hicks contractions.

🤰 Probable signs differ from presumptive signs because they can be observed by another person.

❌ Urinary frequency

❌ Urinary frequency is a presumptive sign of pregnancy because it is subjective and reported by the client.

❌ It may also occur from conditions unrelated to pregnancy.

❌ Amenorrhea

❌ Amenorrhea is considered a presumptive sign, not probable.

❌ Missed menstruation suggests pregnancy but can occur due to stress, illness, or hormonal changes.

❌ Fatigue

❌ Fatigue is also a presumptive sign of pregnancy because it is subjective.

❌ Many conditions other than pregnancy can cause fatigue.

🤰 Rh(D) immune globulin (RhoGAM) is administered to an Rh-negative client to prevent formation of antibodies against Rh-positive fetal blood cells.

🤰 It is indicated after events that increase the risk of fetomaternal blood mixing, including miscarriage, abortion, ectopic pregnancy, invasive procedures, abdominal trauma, and delivery.

🤰 A miscarriage at 14 weeks gestation places the client at risk for exposure to fetal red blood cells, making Rh(D) immune globulin appropriate.

🤰 Administration helps prevent Rh sensitization, which can affect future pregnancies and lead to hemolytic disease of the fetus and newborn.

🤰 Timing is important—Rh immune globulin is generally administered within the recommended timeframe after exposure.

❌ A client who had surgical placement of a cervical cerclage at 13 weeks of gestation

❌ Cervical cerclage alone is not the classic indication expected in this question unless there is documented fetomaternal hemorrhage.

❌ Pregnancy loss events have higher priority for Rh prophylaxis.

❌ A client who has gestational hypertension

❌ Gestational hypertension alone does not cause fetal blood exposure requiring Rh immune globulin.

❌ Management focuses on maternal and fetal monitoring.

❌ A client who has hyperemesis gravidarum

❌ Hyperemesis affects nutrition and hydration but does not involve fetal blood exposure.

❌ Rh immune globulin is not indicated for nausea and vomiting.

🚨 Four saturated perineal pads within 1 hour at 4 hr postpartum strongly suggests postpartum hemorrhage (PPH) and requires immediate intervention.

🚨 The nurse should first assess the uterine fundus and perform fundal massage because the most common cause of early postpartum hemorrhage is uterine atony (failure of the uterus to contract).

🚨 A boggy uterus allows excessive bleeding from uterine vessels that supplied the placenta.

🚨 Fundal massage stimulates uterine contraction, promotes vessel compression, and may rapidly decrease blood loss.

🚨 This action follows the nursing priority of addressing the most likely and reversible cause first before medication administration.

❌ Administer misoprostol

❌ Misoprostol is a uterotonic and may be needed, but assessment of uterine tone comes first.

❌ Medication administration should follow rapid evaluation of the cause of bleeding.

❌ Increase maintenance IV fluid

❌ IV fluids may support circulation, but they do not correct the source of hemorrhage.

❌ Stopping blood loss takes priority.

❌ Perform perineal hygiene

❌ Perineal care is not the immediate priority during active postpartum bleeding.

❌ Hemorrhage assessment and stabilization are urgent.