The nurse is caring for a client in labor. Which signs and ...

[ap345]

The nurse is caring for a client in labor. Which signs and symptoms would indicate the client is progressing into the second stage of labor? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply.
 
  1. Bulging perineum
  2. Increased bloody show
  3. Spontaneous rupture of the membranes
  4. Uncontrollable urge to push
  5. Inability to breathe through contractions

Question 2

The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate?
 
  1. Place a gloved finger in the newborn's mouth.
  2. Take the vital signs.
  3. Wait until the newborn stops crying.
  4. Place a hot water bottle in the isolette.

[ecabral0]

Answer to Question 1

1, 2, 4
Explanation: 1. As the fetal head continues its descent, the perineum begins to bulge, flatten, and move anteriorly.
2. Bloody show increases as a woman enters the second stage of labor.
4. As the fetal head descends, the woman has the urge to push because of pressure of the fetal head on the sacral and obturator nerves.

Answer to Question 2

1
Rationale 1: To soothe a newborn during assessment or other procedures, the nurse can place a gloved finger into the newborn's mouth.
Rationale 2: Crying increases heart rate and respiratory rate, so vitals should not be taken when the newborn is crying.
Rationale 3: Assessment of vitals needs to be done at regularly timed intervals, so waiting until the newborn stops crying might cause too long a delay.
Rationale 4: A hot water bottle should not be placed next to the newborn because of the risk for burns.

[ap345]

Excellent

[Liddy]

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