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: Blood pressure, heart rate, and temperature are vital signs that should be monitored in any client, but they are not laboratory results. ESRD can cause hypertension and cardiovascular complications, so blood pressure and heart rate should be controlled with medications and lifestyle modifications. Temperature should be monitored for signs of infection or inflammation.

Choice B reason: Leukocytes, neutrophils, and thyroxine are not specific laboratory results for ESRD. Leukocytes and neutrophils are types of white blood cells that indicate immune system activity and infection. Thyroxine is a thyroid hormone that regulates metabolism and growth. ESRD can affect the immune system and the thyroid function, but these are not the primary indicators of renal function.

Choice D reason: Erythrocytes, hemoglobin, and hematocrit are laboratory results that measure red blood cell count, oxygen-carrying capacity, and blood volume. ESRD can cause anemia due to reduced production of erythropoietin, a hormone that stimulates red blood cell formation in the bone marrow. Anemia can cause fatigue, pallor, shortness of breath, and chest pain. However, these are not the most significant laboratory results for ESRD.

A. Strain all urine B. Maintain contact isolation C. Avoid urinary catheterization D. Restrict oral fluid intake

Correct Answer is C

Explanation

Choice A: Straining all urine is not a relevant instruction for the nurse to provide, as this is not related to prostatitis. This is a distractor choice.

Choice B: Maintaining contact isolation is not a necessary instruction for the nurse to provide, as prostatitis is not a contagious condition. This is another distractor choice.

Choice C: Avoiding urinary catheterization is an important instruction for the nurse to provide, as this can introduce bacteria into the urinary tract and worsen the infection. Therefore, this is the correct choice.

Choice D: Restricting oral fluid intake is not an appropriate instruction for the nurse to provide, as this can lead to dehydration and reduced urine output, which can increase the risk of urinary stasis and infection. 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

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD.?

Correct Answer is C

Explanation

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding this client?

Correct Answer is C

Explanation

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Which statement should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?