Which nursing intervention is indicated for the second stage of labor?

Monitoring effects of oxytocin administration to help achieve cervical dilation.

Assessing the fetal heart rate and pattern for signs of fetal distress.

Providing pain medication to increase the client's tolerance of labor pains.

Assisting the client to push effectively so that expulsion of the fetus can be achieved.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Monitoring effects of oxytocin administration to help achieve cervical dilation: This is appropriate during the first stage of labor. The second stage begins after full dilation, so oxytocin’s role in cervical change is no longer relevant at this point.

B. Assessing the fetal heart rate and pattern for signs of fetal distress: FHR monitoring is important throughout labor, including the second stage, but it is not unique to this phase. It supports safe delivery but does not directly facilitate the main goal of this stage—fetal expulsion.

C. Providing pain medication to increase the client's tolerance of labor pains: Pain management is crucial, but narcotics are typically avoided in the second stage due to potential neonatal respiratory depression. Also, this does not address the primary task of this stage.

D. Assisting the client to push effectively so that expulsion of the fetus can be achieved:
This is the hallmark intervention of the second stage of labor, where full dilation has occurred and the goal is delivery of the baby. Supporting effective pushing directly aids in achieving this outcome.

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Correct Answer is A

Explanation

Rationale:
A. Elevated liver function tests: Oral antivirals such as acyclovir or valacyclovir are metabolized by the liver, and elevated liver enzymes may indicate hepatotoxicity. This finding is critical and may necessitate discontinuation or dose adjustment to prevent liver damage.

B. Vomiting and diarrhea: These are common side effects of oral antivirals and are usually self-limiting. They typically do not require discontinuation unless they lead to dehydration or are severe and persistent.

C. Decreased white blood cell count: A decreased white blood cell can be a side effect of some antiviral medications, and while it increases the risk of infection, it is usually monitored during long-term therapy. However, in the context of acute shingles treatment with an oral antiviral, elevated liver function tests often represent a more immediate concern.

D. Pruritus and muscle aches: These symptoms may occur with antiviral use but are usually mild and nonspecific. They should be monitored but are not as immediately concerning as signs of liver dysfunction.

A. Assess for discomfort when procedure is completed. B. Verify that the client has given informed consent. C. Instruct the client to keep hands under the sterile field. D. Pour cleansing solution onto the sterile cloth field.

Correct Answer is C

Explanation

Rationale:

A. Assess for discomfort when procedure is completed: Pain assessment is important after the procedure, but it does not address intra-procedural safety. Preventing disruption of the sterile field during the procedure takes priority in this moment.

B. Verify that the client has given informed consent: While consent is essential, it should be obtained before starting the procedure. If the debridement is already underway, verifying consent is no longer the immediate focus for ensuring safety.

C. Instruct the client to keep hands under the sterile field: A mildly confused client may unintentionally contaminate the sterile field. Providing clear instructions to keep hands away helps preserve sterility and reduces the risk of infection.

D. Pour cleansing solution onto the sterile cloth field: Pouring solution directly onto the sterile cloth can compromise the integrity of the sterile field. Cleansing solutions should be poured into sterile containers, not directly on the field, to maintain proper technique.

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Which nursing intervention is indicated for the second stage of labor?

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