Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth
Select one:
Bulging of the vulva
The membranes rupture during a contraction
The fetal head is felt at 0 station during vaginal examination
Bloody mucus discharge increases
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 B
Explanation
a. A woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago with normal fetal movements is not a priority assessment as long as there are no signs of fetal distress.
b. A woman who is 9 cm dilated and fully effaced and is requesting to go to the bathroom to have a bowel movement is in the second stage of labor, which means that the cervix is fully dilated and the fetus is descending in the birth canal. The urge to have a bowel movement is a sign that the fetal head is pressing on the rectum and that delivery is imminent. This patient needs immediate attention and preparation for delivery.
c. A woman at 27 weeks' gestation who noted scant vaginal bleeding today after having sexual intercourse in the morning may be experiencing placenta previa or placental abruption but this is not a priority compared to the woman in option b who is yet to deliver.
d. A woman who is 2 cm dilated and 80% effaced and is crying and shows mild anxiety is not a priority assessment as long as there are no signs of fetal distress.
Correct Answer is B
Explanation
a. Bacterial vaginosis may present with a vaginal discharge that is often grayish-white with a fishy odor, but it does not typically cause inflammation of the vulva.
b. Trichomoniasis can cause inflammation of the vagina and vulva, along with a frothy, greenish-yellow discharge with a strong fishy odor.
c. Chlamydia may cause vaginal discharge but typically does not present with a strong fishy odor.
d. Candidiasis (yeast infection) may cause inflammation and itching of the vulva, but the discharge is typically white, thick, and cottage cheese-like, not greenish with a fishy odor.
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