A 28-year-old female client is in the second stage of labor in the maternity ward.
A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.
Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While Type 1 diabetes is a significant health concern, it is not the most prevalent form of diabetes. Type 2 diabetes is more common, affecting a larger proportion of the population.
Choice B rationale
Type 2 diabetes often remains undiagnosed because its symptoms can be subtle and develop slowly. People with Type 2 diabetes may not recognize these symptoms as signs of high blood sugar, leading to a delay in diagnosis and treatment.
Choice C rationale
Type 1 diabetes cannot transition to Type 2 diabetes. These are distinct conditions with different underlying causes. Type 1 diabetes is an autoimmune condition, while Type 2 diabetes is primarily associated with lifestyle factors and genetic predisposition.
Choice D rationale
Gestational diabetes mellitus (GDM) does not imply that the woman will require insulin treatment until 6 weeks postpartum. While some women with GDM may require insulin during pregnancy, this is not always the case. Furthermore, GDM usually resolves after delivery.
Correct Answer is B
Explanation
Cervical dilation is a key sign that a patient is in labor. As labor progresses, the cervix dilates to allow the baby to pass through the birth canal. Other signs of labor can include regular contractions, rupture of membranes (amniotic fluid present in the vaginal vault), and changes in vaginal discharge.
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