What nursing intervention is particularly indicated for the second stage of labor?
Providing pain medication to increase the client's tolerance of labor pains
Assessing the fetal heart rate and pattern for signs of fetal distress
Assisting the client to push effectively so that expulsion of the fetus can be achieved
Monitoring effects of oxytocin administration to help achieve cervical dilation
The Correct Answer is C
Choice A reason: Providing pain medication to increase the client's tolerance of labor pains is not a specific intervention for the second stage of labor. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Pain medication can be given during any stage of labor, depending on the client's preference and condition. However, pain medication may have side effects such as sedation, nausea, or respiratory depression, and may affect the fetal heart rate or the progress of labor.
Choice B reason: Assessing the fetal heart rate and pattern for signs of fetal distress is not a particular intervention for the second stage of labor. Fetal heart rate and pattern are indicators of fetal well-being and oxygenation. Fetal heart rate and pattern should be monitored throughout labor, especially during contractions, to detect any abnormalities or complications such as bradycardia, tachycardia, or decelerations.
Choice C reason: This is the correct answer because assisting the client to push effectively so that expulsion of the fetus can be achieved is a vital intervention for the second stage of labor. The second stage of labor begins when the cervix is fully dilated (10 cm) and ends with the delivery of the baby. The nurse should coach the client to push with each contraction, using proper breathing and positioning techniques, and provide feedback and encouragement.
Choice D reason: Monitoring effects of oxytocin administration to help achieve cervical dilation is not a relevant intervention for the second stage of labor. Oxytocin is a hormone that stimulates uterine contractions and cervical dilation. Oxytocin can be administered during labor to augment or induce labor, especially if there is prolonged or dysfunctional labor. However, oxytocin is not needed in the second stage of labor, when the cervix is already fully dilated and the focus is on pushing and delivering the baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Assessing pupillary response to light hourly is not related to dopamine administration. Dopamine does not affect the pupils or the cranial nerves that control them.
Choice B reason: Initiating seizure precautions is not necessary for a client receiving dopamine. Dopamine does not lower the seizure threshold or cause convulsions.
Choice C reason: Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine increases blood pressure and cardiac output, which improves renal perfusion and urine production. Urinary output is an indicator of the effectiveness of dopamine therapy and renal function.
Choice D reason: Monitoring serum potassium frequently is not directly related to dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia. However, potassium levels may be affected by other factors such as fluid balance, renal function, and medications.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because getting an eye examination with an ophthalmologist annually is an important point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the eyes, leading to vision problems and eye diseases such as diabetic retinopathy, cataracts, and glaucoma. Regular eye check-ups can help detect and treat these conditions early and prevent blindness.
Choice B reason: Arranging diet schedule around three regular meals a day is not a sufficient point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus is a condition that affects the body's ability to produce or use insulin, a hormone that regulates blood glucose levels. Eating three regular meals a day may not be enough to control blood glucose levels and prevent complications such as hypoglycemia or hyperglycemia. The nurse should teach the client to follow a balanced diet that includes carbohydrates, proteins, fats, vitamins, minerals, and fiber, and to eat smaller portions more frequently throughout the day.
Choice C reason: Using garlic, herbs, and spices will improve the flavor of food is not a specific point for disease and symptom management for a client with type 2 diabetes mellitus. Garlic, herbs, and spices are natural ingredients that can enhance the taste and aroma of food, but they do not have a direct impact on blood glucose levels or diabetes complications. The nurse should teach the client to limit the intake of salt, sugar, and saturated fats, and to choose foods that are low in glycemic index and high in antioxidants.
Choice D reason: Inspecting feet every month for ingrown nails, cuts, and calluses is not a frequent enough point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the feet, leading to reduced sensation, poor circulation, infection, ulceration, and amputation. The nurse should teach the client to inspect feet every day for any signs of injury or infection, and to wash, dry, moisturize, and protect them properly. The nurse should also advise the client to wear comfortable shoes and socks, avoid walking barefoot, and seek medical attention for any foot problems.
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