The nurse is caring for a 13-year-old client who is in labor. ...

[WhattoUnderstand]

The nurse is caring for a 13-year-old client who is in labor. What actions should the nurse take to support this client's needs? Select all that apply.
 
  1. Provide simple and concrete explanations.
  2. Stay with the client during the labor process.
  3. Provide soothing encouragement during the transition phase.
  4. Provide positive reinforcement with a nonjudgmental manner.
  5. Remain calm and provide clear directions during the second stage.

Question 2

The nurse is caring for a client in the second stage of labor. What assessment findings indicate that birth is imminent? Select all that apply.
 
  1. Drop in blood pressure
  2. Increased bloody show
  3. Bulging of the perineum
  4. Subjective feeling of faintness
  5. Uncontrollable urge to bear down

[Jadwiga9]

Answer to Question 1

1, 2, 3, 5
Explanation:
1. For the very young adolescent client, instructions and explanations should be simple and concrete.
2. The very young adolescent needs someone to rely on at all times during labor.
3. During the transition phase, the young teenager may become withdrawn and unable to express her need to be nurtured. Soothing encouragement helps her maintain control and meets her needs for dependence.
4. Positive reinforcement and a nonjudgmental manner are appropriate for a middle adolescent in labor.
5. During the second stage of labor it is important for the nurse to remain calm and give clear, simple directions to help the teen cope with feelings of helplessness.

Answer to Question 2

2, 3, 5
Explanation:
1. A drop in blood pressure could be due to blood loss or dehydration. It is not an indication that birth is imminent.
2. Birth is imminent if the woman has increased bloody show.
3. Birth is imminent if the woman has bulging of the perineum.
4. Subjective feeling of faintness can be due to hyperventilation. The nurse needs to coach the client to slow the rate of breathing.
5. Birth is imminent if the woman has an uncontrollable urge to bear down.