A nurse is assisting with the care of a client who is in labor.
Which of the following findings should the nurse report to the provider?

Rationale for Choice A:

Having the client pant during the next few contractions is not appropriate at this time. While panting can be a helpful

breathing technique during earlier stages of labor, it is not recommended when the client feels the urge to push.

Panting can actually delay the progress of labor by preventing the client from bearing down effectively.

It is important to allow the client to push when she feels the urge, as this will help to facilitate the descent of the fetal head and

progress labor.

Rationale for Choice B:

Helping the client to the bathroom to empty her bladder is not the priority action at this time. While a full bladder can

sometimes interfere with labor progress, it is more important to assess the perineum for signs of crowning before taking the

client to the bathroom.

If the fetal head is crowning, it is crucial to avoid any unnecessary delays in delivery.

Rationale for Choice C:

Assisting the client into a comfortable position is important for labor progress, but it is not the priority action at this time.

Assessment of the perineum for signs of crowning takes precedence, as it will guide the nurse's subsequent actions.

Once crowning is confirmed, the nurse can then help the client into a position that facilitates pushing, such as squatting, semi-

sitting, or side-lying.

Rationale for Choice D:

Assessing the perineum for signs of crowning is the most appropriate action for the nurse to take in this situation.

Crowning is the term used to describe the appearance of the fetal head at the vaginal opening.

It is a definitive sign that the client is in the second stage of labor and that delivery is imminent.

By assessing for crowning, the nurse can confirm the progress of labor and prepare for the delivery of the baby.

Choice A rationale:

When breastfeeding, it’s important for the baby to latch onto not just the nipple, but also some of the areola, which is the

darker circle of skin around the nipple. This allows the baby to get a deep latch, which is necessary for effective breastfeeding.

The baby’s chin should be firmly touching the breast, and their mouth should be wide open. When they attach, you should see

much more of the darker nipple skin above the baby’s top lip than below their bottom lip.

Choice B rationale:

While it’s true that babies have certain instincts when it comes to breastfeeding, they still need guidance and proper

positioning to latch correctly. Simply relying on the baby’s instincts may not ensure a proper latch, which could lead to

ineffective breastfeeding and potential discomfort for the mother.

Choice C rationale:

The size of the baby’s mouth does not determine how much of the nipple they should take in. Regardless of the size of the

baby’s mouth, they should still latch onto the nipple and some of the areola for effective breastfeeding. Taking only part of the

nipple could lead to a shallow latch, which can cause nipple pain and may not allow the baby to get enough milk.

Choice D rationale:

While it’s important for the baby to take in a good amount of the breast tissue, including the nipple and areola, during

breastfeeding, suggesting to include some breast tissue beyond the areola might be excessive. The key is to ensure a deep

latch, which typically involves the nipple and some of the areola, rather than the entire areola and additional breast tissue.