Encourage voiding:A boggy uterus that is displaced above and to the right of the umbilicus often indicates that the bladder may be distended, which can push the uterus out of its normal position and prevent it from contracting properly. Encouraging the client to void can help to reduce bladder distension and allow the uterus to return to its normal position and firm up.

Notify healthcare provider:While this may ultimately be necessary if the problem persists or other complications are noted, the immediate action should be to address the most common cause of uterine displacement, which is bladder distension.

Inspect the perineal pad:
Checking the perineal pad can give clues about the amount of lochia (postpartum vaginal discharge). However, in this scenario, the priority lies in addressing the potential uterine atony.

Monitor vital signs:
While it's important to monitor vital signs, especially in postpartum clients, the priority here is recognizing and managing the potential uterine atony.

A. Insert a Foley catheter with a urimeter to monitor hourly output: This is a reasonable intervention because magnesium sulfate can affect renal function, and monitoring urinary output is essential. However, there's a more critical intervention to consider first.

B. Have calcium gluconate immediately available: This is the highest priority. Magnesium sulfate toxicity can lead to neuromuscular blockade, and calcium gluconate is the antidote. Having it readily available is crucial in case signs of magnesium toxicity (such as loss of deep tendon reflexes) appear.

C. Provide a quiet environment with subdued lighting: While maintaining a calm environment is generally important for clients on magnesium sulfate, it is not the highest priority in this situation.

D. Assess deep tendon reflexes (DTRs) every 4 hours: This is an important part of monitoring for magnesium sulfate toxicity. However, the immediate availability of calcium gluconate is the highest priority in case toxicity occurs.

A. Determine fetal position by performing Leopold maneuvers:
Leopold maneuvers are used to determine the fetal position and presentation by palpating the mother's abdomen. While this information can be valuable, it's not the highest priority in a situation where there is significant vaginal bleeding.

B. Assess the fetal heart rate and client's contraction pattern:
This is the highest priority because it directly addresses the immediate concern. Monitoring the fetal heart rate and contraction pattern helps to assess the well-being of both the mother and the baby.

C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration:
While determining Rh status is important, it may not be the immediate priority in this situation. However, if there is a need for Rho(D) immunoglobulin administration, it should be addressed in a timely manner.

D. Perform sterile vaginal examination to determine dilatation:
Performing a sterile vaginal examination is an important aspect of assessing the progress of labor, but it may not be the highest priority when there is significant vaginal bleeding. The focus initially should be on assessing the fetal heart rate and contraction pattern.

A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.

B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.

C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.

D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.

A. Flaring of the nares:
Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.

B. Shallow and irregular respirations:
Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.

C. Respiratory rate of 50 breaths per minute:
While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.

D. Abdominal breathing with synchronous chest movement:
Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.

A. Unilateral lower leg pain:
Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.

B. Soft, spongy fundus:
A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.

C. Saturating two perineal pads per hour:
Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.

D. Pulse rate of 56 beats/minute:
A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.

Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.

Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.

Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.

Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.

Prepare for a cesarean section:Active herpes lesions are a contraindication for vaginal delivery due to the risk of transmitting the herpes simplex virus (HSV) to the newborn. A cesarean section is necessary to prevent the baby from coming into direct contact with the herpes lesions and reduce the risk of neonatal herpes infection.

Cover the lesion with a dressing:While covering the lesion might be part of overall care, it does not address the primary concern of preventing transmission to the newborn during delivery.

Obtain blood cultures:
Obtaining blood cultures may not be the primary action in this situation. The concern is more related to preventing the transmission of the herpes virus to the newborn.

Administer penicillin:
Penicillin is not the treatment for herpes. Antiviral medications such as acyclovir are typically used for the treatment of herpes infections.

A. Discuss options for intrauterine surgical correction of congenital defects:At this point, the AFP result is only an indicator, not a diagnosis. The client has not undergone sufficient diagnostic evaluation (such as ultrasound) to confirm any congenital defect that would warrant intrauterine surgery. Treatment options can only be discussed once a definitive diagnosis has been made.

B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated:While a repeat AFP test could be done in some cases to rule out lab error or confirm the result, this is not typically the immediate next step. An ultrasound provides more definitive and comprehensive information than simply repeating the AFP test.

C. Reassure the client that the AFP results are likely to be a false reading:Providing false reassurance may lead to misunderstandings. While false positives can happen, it's crucial to follow up with further assessments to ensure the accuracy of the results.

D. Explain that a sonogram should be scheduled for definitive results:An elevated AFP level is a screening test, not a definitive diagnosis. A sonogram (ultrasound) is the next step to obtain more detailed information about the fetus. Ultrasound can help assess for neural tube defects, confirm gestational age, and check for other anomalies that could explain the elevated AFP levels. This provides the most accurate and non-invasive method for evaluating potential fetal abnormalities.

To solve this problem, the nurse needs to convert the units of oxytocin from units to milliunits.

One unit of oxytocin is equal to 1000 milliunits, so 10 units of oxytocin is equal to 10,000 milliunits.

- The concentration of oxytocin in the solution is 10,000 milliunits per 1000 mL, or 10 milliunits per mL.

- To deliver 2 milliunits per minute, the nurse needs to infuse 0.2 mL per minute of the solution.

- To convert from mL per minute to mL per hour, the nurse needs to multiply by 60 minutes per hour.

- Therefore, the nurse should program the infusion pump to deliver 0.2 x 60 = 12 mL per hour of the solution.