A client is in labor and actively pushing.
The nurse observes decelerations in the fetal heart rate and the fetal head is at the vaginal station.

What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that
condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

The client is in the second stage of labor.

The nurse should apply an oxygen mask to the client.

The nurse should press down on the uterine fundus.

The nurse should monitor the client’s vital signs and fetal heart rate.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:

The client is in the second stage of labor because she is actively pushing and the fetal head is at the vaginal station.

The second stage of labor is defined as the time from full cervical dilation to the birth of the baby. It is characterized by strong,

regular contractions and the urge to push.

Decelerations in the fetal heart rate can occur during the second stage of labor due to a variety of factors, including head

compression, cord compression, and uteroplacental insufficiency.

Choice B rationale:

The nurse should apply an oxygen mask to the client to increase the oxygen supply to the fetus.

This can help to improve fetal heart rate and prevent further decelerations.

Oxygen is a vital nutrient for the fetus, and it is essential for maintaining a normal fetal heart rate.

When the fetal heart rate decelerates, it is a sign that the fetus is not getting enough oxygen.

Applying an oxygen mask to the mother can help to increase the amount of oxygen that is available to the fetus.

Choice D rationale:

The nurse should monitor the client's vital signs and fetal heart rate to assess the client's progress and the well-being of the

fetus.

Vital signs, such as blood pressure, pulse, and respiration rate, can provide important information about the mother's health

and how she is coping with labor.

The fetal heart rate is a direct measure of the fetus's well-being.

By monitoring these parameters, the nurse can identify any potential problems and intervene as needed.

Additional notes:

The nurse should also encourage the client to change positions, as this can help to relieve cord compression.

The nurse should also prepare for the possibility of a rapid delivery, as decelerations in the fetal heart rate can sometimes be a

sign of fetal distress.

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Correct Answer is D

Explanation

Choice A rationale:

Placing pillows under the client's knees can actually increase the risk of thrombophlebitis. This is because it flexes the knees,

which can cause blood to pool in the legs. This pooling of blood can lead to the formation of blood clots.

Choice B rationale:

Keeping the client on bed rest is also a risk factor for thrombophlebitis. This is because immobility can cause blood to pool in

the legs. It's important to encourage early and frequent ambulation to promote venous return and prevent clot formation.

Choice C rationale:

Applying warm, moist soaks to the client's lower legs can help to relieve the symptoms of thrombophlebitis, but it does not

prevent it. Warm compresses can help to improve circulation and reduce inflammation, but they're not a preventative

measure.

Choice D rationale:

Encouraging the client to ambulate frequently is the most effective way to prevent thrombophlebitis. This is because it helps to

promote venous return and prevent blood from pooling in the legs. Ambulation also helps to activate the calf muscles, which

act as a natural pump to help move blood back to the heart.

A. I will stop breastfeeding until I am done with the antibiotics B. Apply cold compresses 20 min before each feeding C. Feed my baby every 2 hours D. I won't wear a bra during the daytime

Correct Answer is C

Explanation

Choice A rationale:

Stopping breastfeeding until the antibiotics are done is not a recommended practice. Most antibiotics are safe to use while

breastfeeding. Moreover, stopping breastfeeding can lead to engorgement.

Choice B rationale:

Applying cold compresses 20 minutes before each feeding is not a recommended practice. Cold compresses are usually

recommended after breastfeeding to help reduce swelling. Warm compresses or taking a warm shower before breastfeeding

can help increase milk flow and promote the letdown reflex.

Choice C rationale:

Feeding the baby every 2 hours is a good practice to prevent breast engorgement. Frequent feeding helps to empty the breasts,

which can prevent them from becoming overly full and engorged.

Choice D rationale:

Not wearing a bra during the daytime is not a recommended practice. Wearing a well-fitted bra can provide support and help

reduce discomfort associated with breast engorgement.

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Nursing Test Bank

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A nurse is caring for a client who is 1 day postpartum following a cesarean birth.To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client’s care?

Correct Answer is D

Explanation

A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn.Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

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