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."

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) A postpartum individual can have lochia rubra at 5 weeks postpartum:
Lochia rubra is the first stage of lochia, consisting of bright red blood and tissue, and is typically seen in the first 3-4 days postpartum. By 5 weeks postpartum, the lochia should no longer be in the rubra phase, and the discharge should have progressed to lochia serosa or alba. If the client is still experiencing lochia rubra at 5 weeks, this could indicate a problem, such as retained placental tissue or infection, and requires further evaluation.

B) A postpartum individual should not have any lochia at 5 weeks postpartum:
While it is true that lochia should be minimal or absent by 5 weeks postpartum, it is not uncommon for some women to still experience small amounts of lochia, particularly in the form of lochia alba, which can last up to 6 weeks. The type of discharge should be assessed, and if the discharge is abnormal (such as foul-smelling or accompanied by other symptoms), the nurse should investigate further. However, some amount of discharge, especially lochia alba, can be normal at this stage.

C) A postpartum individual can have lochia serosa up to 6 weeks postpartum:
Lochia serosa, which is pinkish or brownish in color and consists of blood, mucus, and uterine tissue, usually occurs between 4 to 10 days postpartum. It is not typically seen at 5 weeks postpartum unless there is a delay in the normal progression of lochia stages. By 5 weeks postpartum, lochia serosa should have already transitioned to lochia alba, a whitish or yellowish discharge.

D) A postpartum individual can have lochia alba ranging from 10 to 14 days and up to weeks postpartum:
Lochia alba is the final stage of lochia and typically starts around 10–14 days postpartum, lasting up to 6 weeks in some women. It consists mainly of leukocytes, epithelial cells, and mucus, and it is usually white or yellowish in color. This type of discharge is normal in the later weeks postpartum, and its presence at 5 weeks is considered a normal finding as long as it is not accompanied by foul odor, significant odor, or other signs of infection.

A. Dry and stimulate newborn with towel. B. Place a hat on the newborn's head. C. Maintain the delivery room temperature at 20° C (68° F) D. Place a blanket on top of maternal dent and newborn.

Correct Answer is C

Explanation

A) Dry and stimulate newborn with towel:
Drying and stimulating the newborn immediately after birth is a standard practice to prevent heat loss and promote early bonding. This action helps to prevent heat loss through evaporation and stimulates the newborn to breathe. It is an appropriate intervention to reduce the risk of hypothermia, not increase it.

B) Place a hat on the newborn's head:
Placing a hat on the newborn’s head is an appropriate and helpful intervention. Since a significant amount of heat is lost through the head, especially in newborns who have a larger surface area relative to their body mass, keeping the head covered with a hat helps to retain warmth and reduce the risk of hypothermia. This would not place the newborn at risk for hypothermia.

C) Maintain the delivery room temperature at 20° C (68° F):
A delivery room temperature of 20° C (68° F) is on the lower end of the recommended range for newborn care. Newborns are particularly susceptible to heat loss due to their high surface area-to-body weight ratio and immature thermoregulation system. A cooler environment like 20°C increases the risk of hypothermia, as the newborn will lose heat more quickly than it can generate on its own.

D) Place a blanket on top of maternal and newborn:
Placing a blanket over the mother and newborn is an appropriate intervention to prevent heat loss. This promotes warmth by reducing heat loss from the newborn's body surface to the cooler environment. This would not place the newborn at risk for hypothermia; instead, it helps to maintain body temperature.

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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?

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