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 B

Explanation

A) Milia:
Milia are tiny white or yellowish cysts that appear on a newborn's face, particularly on the nose, chin, or forehead. They are caused by the accumulation of keratin under the skin. Milia usually disappear within a few weeks of life and are not related to the pinkish marks described in the question.

B) Telangiectatic nevi (stork bites):
This finding is consistent with telangiectatic nevi, also known as stork bites. These are flat, irregular, pinkish-red marks often found on the forehead, eyelids, and nape of the neck. They are caused by dilated capillaries in the skin and are common in newborns. The marks blanch when pressed and are usually harmless, disappearing within the first 1-2 years of life. This is the correct answer based on the description provided in the question.

C) Nevus flammeus (port wine stain):
A port wine stain is a dark red to purple, flat birthmark caused by capillary malformations. Unlike stork bites, a port wine stain does not blanch when pressed and is typically present for life. It usually appears on the face, neck, or arms, and the coloration remains the same over time.

D) Nevus vasculosus (strawberry mark):
A strawberry mark is a raised, red, and bumpy birthmark that results from proliferation of capillaries. These marks typically appear in the first few weeks of life and grow in size before eventually shrinking and disappearing by the age of 5-10 years. Strawberry marks are not flat, pinkish, or blanchable, making this option unlikely in the scenario described.

A. Contractions that increase in intensity B. Leakage of fluid from the vagina C. increased bladder pressure D. Blood-tinged vaginal mucus E. Uterine contractions that decrease with rest

Correct Answer is ["A","B","D"]

Explanation

A) Contractions that increase in intensity:
This is a hallmark sign of true labor. In true labor, contractions become progressively more intense, frequent, and regular. They also do not subside with rest or changes in activity. The intensity of contractions gradually increases as the cervix dilates and effaces, signaling the onset of labor.

B) Leakage of fluid from the vagina:
Leakage of fluid from the vagina, particularly if it is clear and odorless, is indicative of rupture of membranes, which can occur in true labor. If the membranes rupture and there is a continuous leakage of fluid, it is important for the client to contact the healthcare provider as it may signal the onset of labor. This is a significant sign of labor, especially if accompanied by contractions.

C) Increased bladder pressure:
Increased bladder pressure can occur in pregnancy, especially as the uterus grows and presses on the bladder. However, bladder pressure alone is not a definitive sign of true labor. It can also be a common complaint during late pregnancy, even before labor begins. This symptom would not be specific to true labor.

D) Blood-tinged vaginal mucus:
A bloody show, or blood-tinged mucus, is another classic sign of true labor. This happens as the cervix begins to soften, dilate, and efface, causing small blood vessels in the cervix to break. The bloody show is typically a pink or brownish mucus discharge and can occur just before labor starts, signaling that the cervix is changing in preparation for delivery.

E) Uterine contractions that decrease with rest:
This is a characteristic of false labor (Braxton Hicks contractions). In false labor, contractions tend to decrease or stop when the woman changes position, rests, or hydrates. On the other hand, in true labor, contractions persist and increase in intensity and frequency even with rest or hydration. Therefore, this is not a sign of true labor.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a newborn shortly after birth, the nurse finds flat, irregular pinkish marks the forehead, the nape of the neck and the eyelids. The areas blanch when pressed with a finger. The nurse would document this finding as:

Correct Answer is B

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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