A nurse is teaching a student nurse about the anticipated care of a maternal client with ruptured membranes during the second stage of labor. Which of the following statements by the student indicates an understanding of the teaching?
The client will progress one station every 2 hours
The client should feel the urge to push at -2 station."
Th client's temperature will need to be checked every hour when the membranes have ruptured."
The client's cervix will need to be checked every 30 minutes."
The Correct Answer is C
A) The client will progress one station every 2 hours:
This statement is inaccurate. The progress of labor in terms of fetal station does not follow a predictable or uniform rate. While some progression might occur every hour or two, it varies greatly depending on factors such as the position of the fetus, maternal anatomy, and strength of contractions. Labor can progress at different rates, and not all clients will experience consistent progression every 2 hours.
B) The client should feel the urge to push at -2 station:
This statement is incorrect. The urge to push generally occurs once the fetal head has descended to +1 or +2 station, which is closer to the perineum. At -2 station, the fetal head is still relatively high in the pelvis, and the client typically will not feel the urge to push until the head is lower. The urge to push is often experienced when the fetal head is well engaged in the pelvis and ready for delivery.
C) The client's temperature will need to be checked every hour when the membranes have ruptured:
This statement is correct. Once the membranes have ruptured, there is an increased risk of infection, as the protective barrier of the amniotic sac is no longer intact. Checking the maternal temperature every hour is an essential practice to monitor for signs of infection, such as chorioamnionitis, especially since the longer the rupture lasts, the greater the risk of infection. A rise in temperature is a key indicator of infection in the postpartum period.
D) The client's cervix will need to be checked every 30 minutes:
This is not correct practice. Cervical checks should be performed only when clinically indicated, not routinely every 30 minutes. Frequent cervical checks can increase the risk of infection, especially after the membranes have ruptured. The cervix should be assessed when there is a clinical reason to do so, such as checking for progress in labor or when considering interventions like an epidural or pushing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3.6"]
Explanation
Given:
Desired dose: Ceftazidime 1 g IM every 6 hours
Available concentration: Ceftazidime 280 mg/mL
To find:
Volume to administer (in mL)
Step 1: Convert desired dose to milligrams
1 gram (g) is equal to 1000 milligrams (mg).
Multiply by 1000:
Desired dose (mg) = Desired dose (g) x 1000
Desired dose (mg) = 1 g x 1000 = 1000 mg
Step 2: Set up the proportion
We can use the following proportion to solve the problem:
(Desired dose) / (Available concentration) = Volume to administer
Step 3: Substitute the values
Plugging in the given values, we get:
(1000 mg) / (280 mg/mL) = Volume to administer
Step 4: Simplify
To simplify, we can invert the denominator and multiply:
(1000 mg) x (1 mL / 280 mg) = Volume to administer
The "mg" units cancel out, leaving us with:
(1000 x 1 mL) / 280 = Volume to administer
Step 5: Calculate
Performing the multiplication and division, we get:
1000 mL / 280 = Volume to administer
3.57 mL ≈ Volume to administer
Step 6: Round to the nearest tenth
3.6mL
Correct Answer is ["D","E","I","K"]
Explanation
The newborn's assessment findings that require follow-up:
Temperature 35.7°C (96.3°F) at 2200:
Hypothermia in newborns can lead to cold stress, which increases the risk of respiratory distress and hypoglycemia. The newborn’s temperature should be closely monitored, and warming measures should be initiated to prevent further complications.
Respiratory rate 68/min at 2200:
A respiratory rate above 60 breaths per minute in a newborn is considered tachypnea and can indicate respiratory distress or underlying conditions such as infection. The newborn should be further evaluated to determine the cause of the tachypnea and to ensure proper oxygenation.
Sternal retractions at 2200:
Sternal retractions suggest that the newborn is experiencing increased work of breathing, which is a key sign of respiratory distress. This requires immediate evaluation to assess the severity and identify potential causes, such as respiratory infections or inadequate ventilation.
Coarse rhonchi in bilateral lung fields at 2200:
The presence of coarse rhonchi indicates abnormal breath sounds, often related to fluid retention or infection in the lungs. This finding requires further assessment and possibly interventions to clear the airway and support respiratory function.
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