A woman is in the second stage of labor with a strong urge to push.
Which of the following actions by the nurse is appropriate at this time?
Call and notify the provider the patient would like to push.
Perform a sterile vaginal exam (SVE).
Give supportive words and care to comfort the patient during labor.
Monitor the fetal heart rate tracing for signs of fetal intolerance to labor.
The Correct Answer is B
Choice A rationale
Notifying the provider is important but does not address the immediate need to assess the patient's progress and readiness for delivery. A direct intervention is required to determine the next steps.
Choice B rationale
Performing a sterile vaginal exam allows the nurse to assess cervical dilation and effacement, fetal station, and presentation, which are crucial to determine if the patient is ready to push and proceed with delivery.
Choice C rationale
Supportive words and care are essential for patient comfort, but they do not provide the necessary assessment to determine the patient's progress in labor or readiness for pushing.
Choice D rationale
Monitoring the fetal heart rate tracing is important for assessing fetal well-being but does not specifically address the patient's readiness to push or her labor progress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Effacement and dilation of the cervix are key indicators of true labor. Effacement refers to the thinning of the cervix, and dilation is the opening. True labor leads to progressive changes in the cervix.
Choice B rationale
Rupture of membranes can occur before, during, or after true labor. While it can be associated with labor, it alone does not confirm true labor as cervical changes do.
Choice C rationale
The number of pregnancies (parity) does not determine true labor. True labor is characterized by progressive cervical changes, not by the client's obstetric history.
Choice D rationale
The intensity of contractions alone does not confirm true labor. True labor is marked by regular, progressively stronger contractions leading to cervical effacement and dilation.
Correct Answer is A
Explanation
Choice A rationale
Inadequate weight gain during pregnancy can lead to intrauterine growth restriction (IUGR), where the fetus does not grow as expected.
Choice B rationale
Excess weight gain is not solely due to overeating; it can result from edema, gestational diabetes, or other metabolic factors.
Choice C rationale
Height is a factor in determining a pregnant woman’s target weight range, influencing the overall recommended weight gain.
Choice D rationale
Obese women have higher risks of complications, including gestational diabetes and hypertensive disorders, differing from normal weight women.
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