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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Estrogen is a hormone that plays a crucial role in pregnancy. It helps develop the placenta and triggers increased blood volume and flow throughout pregnancy. However, it is not the primary hormone responsible for maintaining pregnancy.
Choice B rationale
Oxytocin is a hormone that plays a key role in labor and breastfeeding. It causes contractions during labor and helps eject milk during breastfeeding. However, it is not the primary hormone responsible for maintaining pregnancy.
Choice C rationale
Human chorionic gonadotropin (hCG) is a hormone produced during pregnancy. It is made almost exclusively in the placenta and its main function is to maintain the corpus luteum in the ovary and stimulate it to produce progesterone. However, hCG itself is not the primary hormone responsible for maintaining pregnancy.
Choice D rationale
Progesterone is the primary hormone responsible for maintaining pregnancy. It prevents the uterine muscles from contracting prematurely, which could lead to a miscarriage or preterm birth.
Correct Answer is D
Explanation
Choice A rationale
Hypomagnesemia, or low magnesium levels, is not typically a primary concern for newborns of mothers with diabetes mellitus. While it can occur, it is not the priority focus of care.
Choice B rationale
Hyperbilirubinemia, or high bilirubin levels, can lead to jaundice in newborns. However, it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.
Choice C rationale
Hypocalcemia, or low calcium levels, can occur in newborns, but it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.
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