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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) A stool softener as needed:
Fibrinogen levels are elevated during pregnancy as part of the body's natural response to the increased risk of bleeding at birth. While this helps to prevent hemorrhage, it also increases the risk of clot formation, which can lead to postpartum complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). To prevent these complications, one recommended strategy is to use a stool softener. This helps prevent constipation, which can strain the body and increase the risk of developing blood clots due to the Valsalva maneuver during straining. Stool softeners reduce the likelihood of this strain, supporting overall circulation and reducing the risk of clotting.
B) Urinate every two to three hours:
While frequent urination is important for general bladder health, particularly in the immediate postpartum period to avoid urinary retention, it is not directly related to preventing complications associated with elevated fibrinogen levels. Fibrinogen's main risk is related to clotting, and frequent urination does not affect this process.
C) Eat a diet high in protein:
While eating a balanced diet with adequate protein is essential for postpartum recovery and tissue healing, it does not directly address the increased fibrinogen levels or the potential for clotting. A high-protein diet does not significantly reduce the risks related to hypercoagulability during the postpartum period, which is primarily managed through careful monitoring and preventive measures such as using stool softeners or encouraging movement.
D) Walk:
While walking is beneficial for overall health and can help improve circulation, reducing the risk of DVT and promoting postpartum recovery, walking alone may not be sufficient to counteract the increased clotting risk from elevated fibrinogen levels. While movement is important to prevent clots, the use of stool softeners to prevent constipation is a more direct and targeted intervention for preventing strain, which could trigger clot formation. Therefore, walking, while helpful, is not the most specific measure to prevent complications related to increased fibrinogen.
Correct Answer is B
Explanation
Naegele's Rule is a method used to estimate the due date of a pregnancy. It involves the following steps:
- Start with the first day of the client's last menstrual period (LMP).
- Add one year.
- Subtract three months.
- Add seven days.
Using the client's LMP of September 17:
- Start with September 17.
- Add one year: September 17, the following year.
- Subtract three months: June 17 of the following year.
- Add seven days: June 24.
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