The nurse is providing care to the client during the second stage ...

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The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate?
 
  A) Assessing maternal temperature every 2-4 hours after amniotic membranes have ruptured
  B) Encouraging the client to void because a full bladder can interfere with fetal descent
  C) Assessing fetal heart rate every 15 minutes in low risk clients
  D) Administering antibiotics for a positive group beta strep

Question 2

A client with a history of frequent outbursts and fighting has been receiving treatment to help control emotions and anger. Which client statement shows that treatment has been effective?
 
  A) My brothers are the only ones I can fight with and not get in trouble.
  B) There are other ways to deal with anger, and I will use them instead of fighting.
  C) Hitting people is only justified sometimes.
  D) As long as my mother doesn't hit me first, I will not hit her.

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Answer to Question 1

Answer: C

The second stage of labor is reached when the cervix is completely dilated. At this time, it is appropriate for the nurse to assess fetal heart rate every 15 minutes in low risk clients and every 5 minutes in high risk clients. Assessing temperature every 2 to 4 hours after amniotic membranes have ruptured, encouraging the client to void, and administering antibiotics are all nursing actions that are appropriate during the first stage of labor.

Answer to Question 2

Answer: B

A client with a history of frequent outbursts and fighting would demonstrate improvement with interventions by stating that the client will use other ways to deal with anger instead of fighting. Hitting people is never justified. The client should not plan to fight with his brothers. The client should not plan to hit his mother. These are evidence that interventions have not been effective.