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

Choice A reason: 18%. This is not the correct percentage, as it only accounts for one lower extremity. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 18% x 2 = 36%.

Choice B reason: 27%. This is not the correct percentage, as it only accounts for one and a half lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so one and a half lower extremities would account for 9% x 3 = 27%.

Choice C reason: 36%. This is the correct percentage, as it accounts for both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 9% x 4 = 36%.

Choice D reason: 45%. This is not the correct percentage, as it accounts for more than both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so more than both lower extremities would account for more than 9% x 4 = 36%.

Choice A reason: Providing diet low in phosphorus is not a relevant intervention for a client with cirrhosis of the liver. Phosphorus is a mineral that helps maintain bone health and acid-base balance. Cirrhosis of the liver does not affect phosphorus levels, but it can cause low calcium levels due to impaired vitamin D metabolism. The nurse should provide a diet high in calcium and vitamin D to prevent osteoporosis and fractures.

Choice B reason: This is a correct answer because noting signs of swelling and edema is an important intervention for a client with cirrhosis of the liver. Cirrhosis of the liver is a chronic condition that causes scarring and damage to the liver tissue, impairing its function and blood flow. This can lead to portal hypertension, which is increased pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can cause fluid accumulation in the abdomen (ascites) and legs (peripheral edema). The nurse should assess the client's weight, fluid intake and output, abdominal girth, and extremity circumference.

Choice C reason: Increasing oral fluid intake to 1,500 mL daily is not a suitable intervention for a client with cirrhosis of the liver. Fluid intake should be individualized based on the client's fluid status, electrolyte levels, and urine output. Increasing fluid intake may worsen fluid retention and electrolyte imbalance in clients with cirrhosis of the liver. The nurse should restrict fluid intake to 1,000 to 1,500 mL daily or as prescribed by the healthcare provider.

Choice D reason: This is a correct answer because monitoring abdominal girth is an essential intervention for a client with cirrhosis of the liver. Abdominal girth is a measurement of the circumference of the abdomen at the level of the umbilicus. It reflects the amount of fluid in the peritoneal cavity, which can increase due to portal hypertension and hypoalbuminemia in clients with cirrhosis of the liver. The nurse should measure and record abdominal girth daily or more frequently as indicated.

Choice E reason: This is a correct answer because reporting serum albumin and globulin levels is a significant intervention for a client with cirrhosis of the liver. Albumin and globulin are types of proteins that are synthesized by the liver and have various functions in the body, such as maintaining fluid balance, transporting hormones and drugs, and fighting infections. Cirrhosis of the liver can cause low albumin levels due to reduced synthesis and increased loss through ascites or urine. Low albumin levels can cause edema, malnutrition, and increased risk of infection. Cirrhosis of the liver can also cause high globulin levels due to chronic inflammation or immune response. High globulin levels can indicate autoimmune diseases, infections, or malignancies. The nurse should monitor and report serum albumin and globulin levels as they reflect liver function and overall health status.