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 A

Explanation

Choice A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.

Choice B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.

Choice C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.

Choice D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.

A. Ask for a consultation with a psychologist. B. Arrange an appointment with a pain specialist. C. Contact a hospice nurse for an evaluation. D. Form an interdisciplinary team for evaluation.

Correct Answer is B

Explanation

Choice A: Ask for a consultation with a psychologist. This is not the best intervention, as it does not address the physical aspect of pain management. A psychologist may help the client cope with emotional distress and cognitive-behavioral strategies to reduce pain perception, but it may not be enough to relieve severe pain.

Choice B: Arrange an appointment with a pain specialist. This is the best intervention, as it addresses the physical aspect of pain management. A pain specialist may prescribe appropriate medications, perform interventional procedures, or recommend alternative therapies to relieve severe pain.

Choice C: Contact a hospice nurse for an evaluation. This is not the best intervention, as it does not address the eligibility criteria for hospice care. Hospice care is intended for clients who have a terminal illness with a life expectancy of six months or less, and who have decided to forego curative treatments. Fibromyalgia is not a terminal illness, and hospice care may not be appropriate for this client.

Choice D: Form an interdisciplinary team for evaluation. This is not the best intervention, as it does not address the urgency of pain management. An interdisciplinary team may consist of various healthcare professionals who can provide holistic care for the client, but it may take time to coordinate and implement their services.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?

Correct Answer is A

Explanation

A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem?

Correct Answer is B

Explanation

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