A 28-year-old female client is in the second stage of labor in the maternity ward.
A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.
Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The maternal serum alpha-fetoprotein (MSAFP) test is a screening test that measures the level of alpha-fetoprotein in the mother’s blood during pregnancy. It is used to assess the likelihood of certain birth defects, including neural tube defects such as spina bifida.
Choice B rationale
The MSAFP test does not assess fetal lung maturity. Other tests, such as amniocentesis, can be used to assess this.
Choice C rationale
The MSAFP test does not identify Rh incompatibility between the mother and fetus. Rh incompatibility is typically determined through blood typing and antibody screening.
Choice D rationale
While the MSAFP test can provide valuable information about the health of the fetus, it does not assess various markers of fetal well-being. It is specifically used to screen for certain birth defects.
Correct Answer is D
Explanation
Step 1 is to calculate the volume of betamethasone to be drawn up for each dose. The order is to administer betamethasone IM and to repeat the dose after 2 hours. Betamethasone is available as 4mg/mL. Therefore, to administer a dose of 12mg, the nurse would need to draw up 12mg ÷ 4mg/mL = 3mL for each dose.
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