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 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 C

Explanation

Choice A reason: Increasing the intake of dark green leafy vegetables while taking warfarin is not a good instruction because it can decrease the effectiveness of warfarin. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin.

Choice B reason: Eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Stopping warfarin while continuing to eat high amounts of vitamin K can increase the risk of clot formation and thromboembolism.

Choice D reason: Avoiding eating any foods that contain any vitamin K because it is an antagonist of warfarin is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Eliminating vitamin K from the diet can increase the sensitivity to warfarin and cause excessive bleeding and bruising.

A. Determine the need for urinary catheterization B. Titrate oxygen to prescribed parameters. C. Receive a postoperative client and conduct the assessment. D. Evaluate and update plans of care for clients.

Correct Answer is B

Explanation

Choice A: Determining the need for urinary catheterization is not a task that the nurse should assign to the PN, as this requires clinical judgment and critical thinking, which are beyond the scope of practice of the PN. This is a distractor choice.

Choice B: Titrating oxygen to prescribed parameters is a task that the nurse can assign to the PN, as this involves following orders and protocols, which are within the scope of practice of the PN. Therefore, this is the correct choice.

Choice C: Receiving a postoperative client and conducting the assessment is not a task that the nurse should assign to the PN, as this requires initial assessment and data collection, which are the responsibility of the registered nurse. This is another distractor choice.

Choice D: Evaluating and updating plans of care for clients is not a task that the nurse should assign to the PN, as this requires nursing diagnosis and outcome identification, which are part of the nursing process that only the registered nurse can perform. This is another distractor choice.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?

Correct Answer is C

Explanation

The nurse leading a cardiac team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse assign to the PN?

Correct Answer is B

Explanation

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