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","D"]

Explanation

Rationale:

A. Teach client to use incentive spirometer every 2 hours while awake: Using the incentive spirometer promotes lung expansion and helps prevent postoperative pulmonary infections like pneumonia, which are common in older adults after surgery.

B. Assess pain level and medicate PRN as prescribed: Pain management is essential for recovery but does not directly reduce infection risk. While adequate pain control may support deep breathing and mobility, it is not itself an infection-prevention intervention.

C. Maintain sequential compression devices while in bed: Sequential compression devices help prevent deep vein thrombosis but do not directly reduce the risk of infection. They serve a circulatory, not an antimicrobial, purpose.

D. Remove urinary catheter as soon as possible and encourage voiding: Early catheter removal minimizes the risk of catheter-associated urinary tract infections (CAUTIs), which are a major source of healthcare-associated infections in postoperative patients.

E. Administer low molecular weight heparin as prescribed: This medication is used to prevent blood clots, not infection. While important in postoperative care, it does not address infection control directly.

A. Remind the UAP to apply a fitted respirator mask before entering the client's room. B. Assign the UAP to provide care for another client and assume full care of the client. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Instruct the UAP to notify the nurse of any changes in the client's emesis.

Correct Answer is C

Explanation

Rationale:

A. Remind the UAP to apply a fitted respirator mask before entering the client's room:A fitted respirator (such as an N95) is required for airborne precautions (e.g., tuberculosis, measles, or varicella). Because Neisseria meningitidis is transmitted via droplets that do not remain suspended in the air, a standard surgical mask is sufficient. Requiring an N95 mask is an unnecessary level of protection for this specific pathogen.

B. Assign the UAP to provide care for another client and assume full care of the client:
Delegating tasks based on infection risk may be reasonable, but it's not necessary to reassign care if the UAP follows proper precautions.

C. Review the need for the UAP to wear a face mask while in close contact with the client: Droplet Precautions require anyone entering the room or coming within 3 to 6 feet of the client to wear a standard surgical mask. The nurse must ensure the UAP understands that because the client is coughing or vomiting (which can aerosolize droplets), a mask is mandatory to prevent transmission. This intervention prioritizes safety through proper education and adherence to infection control protocols.

D. Instruct the UAP to notify the nurse of any changes in the client's emesis: Monitoring emesis is part of ongoing care but is not as urgent as preventing transmission of a highly contagious illness. Infection control measures must be enforced before other instructions.

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

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Naxlex Comprehensive Predictor Exams

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing interventions should the nurse include in the client's plan of care? Select all that apply.

Correct Answer is ["A","D"]

Explanation

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

Correct Answer is C

Explanation

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