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Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth

Select one:

A.

Bulging of the vulva

B.

The membranes rupture during a contraction

C.

The fetal head is felt at 0 station during vaginal examination

D.

Bloody mucus discharge increases

Answer and Explanation

The Correct Answer is A

a.    Bulging of the vulva: This indicates that the fetal head is descending but does not necessarily mean the woman is almost ready to give birth. This indicates that the fetal head is crowning and putting pressure on the perineum, which means that delivery is imminent.
b.    This indicates that the amniotic sac has ruptured but does not necessarily mean the woman is almost ready to give birth.
c.    The fetal head at 0 station means that it is at the level of the maternal ischial spines, but it still needs to descend further to reach the perineum.
d.    This indicates that the woman is in the early stages of labor but does not necessarily mean she is almost ready to give birth.
 


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Related Questions

Correct Answer is A

Explanation

a. Massaging the client's back can help to close the "gate" for pain signals to reach the brain according to the Gate control theory of pain.
b. Administering analgesic medications addresses pain but does not directly apply the principles of the Gate control theory.
c. Placing the client on a supine position does not specifically address pain control according to the Gate control theory.
d. Repositioning onto her left side may be done for fetal well-being but does not directly apply the principles of the Gate control theory.

Correct Answer is A

Explanation

a. In this case, the woman is pregnant for the fourth time, so her gravidity is 4.

She has one child born at 39 weeks, another child born at 40 weeks, and one child born at 36.2 weeks. The first two are considered term births, and the last one is considered a preterm birth. Therefore, her term is 1 and her preterm is 2. She has no abortions, so her abortion is 0. She has three living children, so her living children is 3. Hence, her GTPAL is 4-2-1-0-3.
b. This indicates 1 full-term pregnancy, 1 preterm pregnancy, and 3 living child.

c. This would indicate 1 full-term pregnancy, 2 preterm pregnancies, and 3 living children.
d. 4-3-0-0-3: This would indicate 3 full-term pregnancies and 3 living children.

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