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","D","E"]
Explanation
Choice A rationale
Human chorionic gonadotropin (hCG) is produced by the placenta, maintaining the corpus luteum and promoting progesterone production crucial for sustaining pregnancy.
Choice B rationale
Testosterone is not produced by the placenta; it is primarily synthesized in the testes and ovaries and not involved in normal pregnancy hormone production.
Choice C rationale
Insulin is not produced by the placenta; instead, it is secreted by the pancreas and regulates blood glucose levels, not directly linked to pregnancy hormones.
Choice D rationale
Estrogen is produced by the placenta, contributing to the development of female secondary sexual characteristics and maintaining the uterine lining during pregnancy.
Choice E rationale
Progesterone is produced by the placenta, supporting the uterine lining's maintenance, preventing contractions, and creating a suitable environment for fetal development.
Correct Answer is D
Explanation
Choice A rationale
Valsalva maneuver involves forced expiration against a closed airway, increasing intrathoracic pressure and commonly used to expel the fetus during the second stage of labor.
Choice B rationale
Ferguson’s reflex involves the release of oxytocin due to vaginal and cervical stretching, leading to stronger contractions during the second stage of labor.
Choice C rationale
Lightening refers to the descent of the fetus into the pelvis before labor begins, reducing pressure on the diaphragm and making breathing easier.
Choice D rationale
Molding is the slight overlapping of cranial bones, allowing the fetal head to change shape and fit through the birth canal during labor.
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