What nursing intervention is particularly indicated for the second stage of labor?

Providing pain medication to increase the client's tolerance of labor pains

Assessing the fetal heart rate and pattern for signs of fetal distress

Assisting the client to push effectively so that expulsion of the fetus can be achieved

Monitoring effects of oxytocin administration to help achieve cervical dilation

Answer and Explanation

The Correct Answer is C

Choice A reason: Providing pain medication to increase the client's tolerance of labor pains is not a specific intervention for the second stage of labor. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Pain medication can be given during any stage of labor, depending on the client's preference and condition. However, pain medication may have side effects such as sedation, nausea, or respiratory depression, and may affect the fetal heart rate or the progress of labor.

Choice B reason: Assessing the fetal heart rate and pattern for signs of fetal distress is not a particular intervention for the second stage of labor. Fetal heart rate and pattern are indicators of fetal well-being and oxygenation. Fetal heart rate and pattern should be monitored throughout labor, especially during contractions, to detect any abnormalities or complications such as bradycardia, tachycardia, or decelerations.

Choice C reason: This is the correct answer because assisting the client to push effectively so that expulsion of the fetus can be achieved is a vital intervention for the second stage of labor. The second stage of labor begins when the cervix is fully dilated (10 cm) and ends with the delivery of the baby. The nurse should coach the client to push with each contraction, using proper breathing and positioning techniques, and provide feedback and encouragement.

Choice D reason: Monitoring effects of oxytocin administration to help achieve cervical dilation is not a relevant intervention for the second stage of labor. Oxytocin is a hormone that stimulates uterine contractions and cervical dilation. Oxytocin can be administered during labor to augment or induce labor, especially if there is prolonged or dysfunctional labor. However, oxytocin is not needed in the second stage of labor, when the cervix is already fully dilated and the focus is on pushing and delivering the baby.

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Correct Answer is ["B","C","E","F"]

Explanation

Choice B reason: weight management is an important factor in preventing and controlling hypertension. Taking daily walks for thirty minutes can help reduce weight and lower blood pressure.

Choice C reason: salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Sodium intake is associated with increased blood pressure and should be limited to less than 2,300 mg per day.

Choice E reason: sodium intake can be regulated by rinsing canned foods in water. Canned foods often contain high amounts of sodium as a preservative and rinsing them can remove some of the excess sodium.

Choice F reason: uncontrolled hypertension can lead to renal damage. Hypertension can cause damage to the blood vessels and impair the function of the kidneys, leading to chronic kidney disease or failure.

Choice A reason: alcohol consumption can produce vascular changes that increase blood pressure. Alcohol intake should be limited to no more than one drink per day for women and two drinks per day for men.

Choice D reason: blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner.

A. Mark an outline of the "olive-shaped" mass in the right epigastric area. B. Maintain a continuous infusion of IV fluids per prescription. C. Monitor amount of intake and infant's response to feedings. D. Instruct parents regarding care of the incisional area.

Correct Answer is B

Explanation

Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.

Choice B reason: This is the correct answer because maintaining a continuous infusion of IV fluids per prescription is essential to prevent dehydration and electrolyte imbalance in the infant. The infant may have significant fluid loss due to vomiting and poor intake.

Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.

Choice D reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.

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What nursing intervention is particularly indicated for the second stage of labor?

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