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 ["A","B","D"]

Explanation

A) Change client position every 30 minutes:
Changing positions regularly during the second stage of labor can help facilitate fetal descent and improve the effectiveness of contractions. This strategy also helps relieve pressure on certain areas of the body, such as the perineum and lower back, promoting more effective pushing and reducing the need for assisted delivery. Frequent position changes can help the mother progress in labor without the need for tools or interventions.

B) Upright positions:
Upright positions, such as standing, squatting, or kneeling, can be beneficial in the second stage of labor. These positions allow gravity to assist in the descent of the baby, which can help avoid the need for forceps or vacuum extraction. Upright positions also tend to open up the pelvis and can result in more effective pushing, reducing the likelihood of an assisted vaginal delivery.

C) Supine positions:
Supine positions (lying on the back) are not recommended for avoiding an assisted vaginal birth. Lying on the back can hinder fetal descent and may also lead to increased pressure on the inferior vena cava, which can decrease blood flow and oxygen to the uterus. This position tends to slow down labor and may increase the need for interventions like forceps or vacuum extraction, making it less favorable for a spontaneous vaginal delivery.

D) Lateral positions:
Lateral positions (lying on one side) can also help in the second stage of labor. This position can improve uterine blood flow, relieve pressure on the perineum, and provide more room for the baby to descend. It is a good alternative to supine positions and can aid in achieving a vaginal birth without assistance.

E) Delayed pushing:
Delayed pushing can be helpful for some clients, especially if they are not fully dilated or if they need time to rest. However, delayed pushing is not directly related to preventing an assisted vaginal birth. In fact, if the mother waits too long to push or doesn't push effectively, it could potentially lead to more complications or require assisted interventions. The key is ensuring that pushing is done effectively and at the right time in the second stage, rather than delaying it unnecessarily.

A. Apply petrolatum to penis with each diaper change B. Use a diaper barrier cream that contains zinc oxide C. Use alcohol-based baby wipes on the soiled genital area D. Fold the diaper below the umbilical cord at all times E. Apply alcohol to the umbilical stump with a diaper change F. Use a soft-bristled brush with mild shampoo to wash the head G. Bathe in a shallow warm tub every other day H. Cover the hands with socks or sleeves at all times I. Apply mildly scented lotion to face as needed

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"B"},"I":{"answers":"B"}}

Explanation

Apply petrolatum to penis with each diaper change: Applying petrolatum prevents the healing circumcision site from adhering to the diaper, reducing pain and promoting proper healing.
Use a diaper barrier cream that contains zinc oxid: Zinc oxide is used for diaper rash treatment but is not routinely necessary. It may interfere with circumcision healing by creating a barrier that retains moisture.
Use alcohol-based baby wipes on the soiled genital area: Alcohol-based wipes can be too harsh on a newborn’s delicate skin and may cause irritation, especially on the healing circumcision site.
Fold the diaper below the umbilical cord at all times: Folding the diaper below the umbilical cord keeps the area dry and exposed to air, promoting natural drying and reducing the risk of infection.
Apply alcohol to the umbilical stump with a diaper change: Alcohol was previously used to dry the cord, but current guidelines recommend keeping it clean and dry, allowing it to fall off naturally.
Use a soft-bristled brush with mild shampoo to wash the head: A soft-bristled brush helps loosen cradle cap (seborrheic dermatitis), preventing buildup of flaky skin without causing irritation.
Bathe in a shallow warm tub every other day: Full immersion bathing should be avoided until the umbilical cord stump falls off to prevent moisture retention and infection. Sponge baths are recommended instead.
Cover the hands with socks or sleeves at all times: While covering hands temporarily can prevent scratches, prolonged covering may interfere with newborn sensory development and exploration.
Apply mildly scented lotion to face as needed: Newborn skin is sensitive, and scented lotions may cause irritation or allergic reactions. If needed, only fragrance-free moisturizers should be used.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the second stage of labor who does not want any tools used to assist with the vaginal birth. Which of the following interventions should the nurse understand will help prevent an assisted vaginal birth? (Select All that Apply.)

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

Explanation

A nurse is assisting in the care of a newborn. Exhibits A nurse is reinforcing discharge education with the parents of a newborn. For each potential point, click to specify if the teaching is anticipated or contraindicated for the newborn.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"B"},"I":{"answers":"B"}}

Explanation

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