A client in the second stage of labor reports to a nurse that they are feeling pain and pressure in their pelvis and perinium. Which of the following should the nurse understand that this pain is caused by?

Uterine contractions

The fetal head applying pressure

Nerve stimulation

Cervical dilation

Answer and Explanation

The Correct Answer is B

A) Uterine contractions:
While uterine contractions cause significant pain and discomfort during labor, particularly in the first and early second stages, by the time the client reaches the second stage of labor, the cervix is fully dilated, and the main cause of pain and pressure is no longer from the contractions themselves. Instead, the pain and pressure described in the second stage are primarily due to the fetal head descending through the birth canal, applying pressure to the perineum.

B) The fetal head applying pressure:
The pain and pressure reported in the second stage of labor are primarily due to the fetal head descending into and through the birth canal, putting pressure on the cervix, vagina, perineum, and pelvic floor. This pressure is a major source of discomfort in the second stage, as the fetal head stretches the tissues of the perineum, which is essential for facilitating birth. The sensation of pressure on the pelvic floor is often described by clients during this stage.

C) Nerve stimulation:
Nerve stimulation occurs during labor as a result of uterine contractions and the fetal descent, which can cause radiating pain to the lower back, thighs, and pelvic region. However, the specific pain and pressure in the pelvis and perineum described by the client are more directly related to the fetal head applying pressure, rather than generalized nerve stimulation. Nerve stimulation may contribute to pain but is not the primary cause of the pelvic and perineal pressure at this stage.

D) Cervical dilation:
Cervical dilation occurs in the earlier stages of labor (latent and active phases), and while it contributes to pain during these stages, by the second stage, the cervix should be fully dilated (10 cm). The pain and pressure that the client is feeling in the second stage are less about cervical dilation and more about the descent of the fetal head through the birth canal and its pressure on the perineum and pelvic floor.

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Correct Answer is A

Explanation

A) A stool softener as needed:
Fibrinogen levels are elevated during pregnancy as part of the body's natural response to the increased risk of bleeding at birth. While this helps to prevent hemorrhage, it also increases the risk of clot formation, which can lead to postpartum complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). To prevent these complications, one recommended strategy is to use a stool softener. This helps prevent constipation, which can strain the body and increase the risk of developing blood clots due to the Valsalva maneuver during straining. Stool softeners reduce the likelihood of this strain, supporting overall circulation and reducing the risk of clotting.

B) Urinate every two to three hours:
While frequent urination is important for general bladder health, particularly in the immediate postpartum period to avoid urinary retention, it is not directly related to preventing complications associated with elevated fibrinogen levels. Fibrinogen's main risk is related to clotting, and frequent urination does not affect this process.
C) Eat a diet high in protein:
While eating a balanced diet with adequate protein is essential for postpartum recovery and tissue healing, it does not directly address the increased fibrinogen levels or the potential for clotting. A high-protein diet does not significantly reduce the risks related to hypercoagulability during the postpartum period, which is primarily managed through careful monitoring and preventive measures such as using stool softeners or encouraging movement.

D) Walk:
While walking is beneficial for overall health and can help improve circulation, reducing the risk of DVT and promoting postpartum recovery, walking alone may not be sufficient to counteract the increased clotting risk from elevated fibrinogen levels. While movement is important to prevent clots, the use of stool softeners to prevent constipation is a more direct and targeted intervention for preventing strain, which could trigger clot formation. Therefore, walking, while helpful, is not the most specific measure to prevent complications related to increased fibrinogen.

A. Flexion B. Engagement C. Extension D. Expulsion

Correct Answer is B

Explanation

A) Flexion:
Flexion is a movement where the fetal head bends forward during labor, which allows the smallest diameter of the head to pass through the birth canal. It is an important part of the labor process but does not refer to the initial descent of the fetus into the pelvis. Flexion typically occurs once the fetus begins to descend into the pelvis.

B) Engagement:
Engagement refers to the initial descent of the fetal head into the pelvis and the passage of the largest part of the fetal head (the biparietal diameter) into the maternal pelvis. This occurs when the fetal head reaches zero station at the level of the ischial spines and is the first cardinal movement of labor. It marks the point at which the presenting part of the fetus enters the pelvic inlet and begins the process of descent.

C) Extension:
Extension is the movement of the fetal head as it exits the birth canal after engagement and descent. The head moves from a flexed position (chin to chest) to an extended position (chin moving away from the chest) as it passes through the birth canal. This movement occurs after engagement and is a part of the expulsion phase, not the initial descent.

D) Expulsion:
Expulsion is the final phase of labor, which occurs after the fetal head has been delivered. It involves the delivery of the rest of the body (shoulders, torso, and legs) following the birth of the head. This is the final cardinal movement, which takes place after engagement, descent, flexion, internal rotation, extension, and external rotation.

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A client in the second stage of labor reports to a nurse that they are feeling pain and pressure in their pelvis and perinium. Which of the following should the nurse understand that this pain is caused by?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is aware that fibrinogen levels are increased in pregnancy. Which measure can be taken to prevent postpartum complications that result because of this increase? Have the client:

Correct Answer is A

Explanation

The nursing, intructor is explaining the cardinal movements of labor to the nursing students. The instructor explains that the initial descent of the fetus into the pelvis to zero station is which one of the cardinal movements of labor.

Correct Answer is B

Explanation

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