Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth
Select one:
Bulging of the vulva
The membranes rupture during a contraction
The fetal head is felt at 0 station during vaginal examination
Bloody mucus discharge increases
The Correct Answer is A
a. Bulging of the vulva: This indicates that the fetal head is descending but does not necessarily mean the woman is almost ready to give birth. This indicates that the fetal head is crowning and putting pressure on the perineum, which means that delivery is imminent.
b. This indicates that the amniotic sac has ruptured but does not necessarily mean the woman is almost ready to give birth.
c. The fetal head at 0 station means that it is at the level of the maternal ischial spines, but it still needs to descend further to reach the perineum.
d. This indicates that the woman is in the early stages of labor but does not necessarily mean she is almost ready to give birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Suctioning the mouth during a seizure can increase the risk of injury and is not recommended.
b. The primary duty of the nurse during a seizure is to ensure the safety of the client by staying with them and calling for assistance.
c. Inserting an oral airway during a seizure is not appropriate and can increase the risk of injury.
d. Administering oxygen may be necessary after the seizure has ended, but the primary duty during the seizure is to ensure safety.
Correct Answer is D
Explanation
a. This is not the correct diagnosis for this situation.
b. This is not the correct diagnosis for this situation.
c. This is not the correct diagnosis for this situation.
d. The sudden onset of increased contraction frequency, dark red vaginal bleeding, and severe abdominal pain are characteristic of placental abruption.
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