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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Group B Streptococcus (GBS) is not typically associated with perineal sepsis; rather, it is a bacterium that colonizes the gastrointestinal and genitourinary tracts.
Choice B rationale
While GBS colonization can pose risks, chorioamnionitis is a different infection involving the membranes and amniotic fluid, often caused by a variety of microorganisms, not solely GBS.
Choice C rationale
GBS is not primarily sexually transmitted; it is a bacterium naturally present in the genital and digestive tracts, and colonization can occur without sexual contact.
Choice D rationale
Neonatal sepsis is a serious risk for babies born to mothers colonized with GBS, necessitating antibiotic prophylaxis to prevent transmission and subsequent infection in the newborn.
Correct Answer is C
Explanation
Choice A rationale
Bladder distention may cause discomfort and urinary issues but is not directly related to cervical dilation and effacement, which involve changes in the cervix to prepare for labor.
Choice B rationale
False labor involves irregular contractions that do not lead to cervical dilation and effacement. These are often called Braxton Hicks contractions and do not result in significant cervical changes.
Choice C rationale
The cervical mucus plug coming out, also known as the "bloody show," indicates that the cervix is beginning to dilate and efface, which are preparatory processes for labor to occur.
Choice D rationale
Lightening refers to the descent of the baby into the pelvis, which typically occurs in the later stages of pregnancy and does not directly involve cervical dilation and effacement processes.
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