A 38-week pregnant woman presents to the labor and delivery unit with regular contractions. The cervix is 3 cm dilated and 80% effaced. What is the next appropriate nursing action?

Correct Answer: D

Rationale: The correct answer is D: Continue to monitor contractions and fetal heart rate. At 3 cm dilated and 80% effaced, the woman is likely in early labor. Continuous monitoring is crucial to assess labor progression and fetal well-being. Vaginal exam (A) can increase infection risk. Preparing for delivery (B) is premature. Administering epidural (C) is based on pain management, not current labor stage. Monitoring contractions and fetal heart rate ensures timely intervention if needed.

Correct Answer: B

Rationale: The correct answer is B: Provide non-pharmacological pain relief methods. In the latent phase of labor, the cervix is dilated up to 6 cm and the contractions are typically mild to moderate. Non-pharmacological methods like massage, breathing techniques, warm showers, and position changes are most appropriate as they help the patient relax and cope with the pain without interfering with the progress of labor. Administering an epidural block (A) is not recommended in the latent phase as it can slow down labor. Administering narcotic analgesics (C) can affect the baby and may not provide adequate pain relief. Encouraging the patient to push (D) is not appropriate in the latent phase as it can lead to exhaustion and may not be effective until the cervix is fully dilated.

Correct Answer: A

Rationale: The correct answer is A: Check for cord prolapse. This is the priority intervention because with ruptured membranes, there is a risk of umbilical cord prolapse, which can lead to fetal compromise. Checking for cord prolapse allows for quick identification and immediate intervention to prevent potential harm to the baby. Choice B is incorrect as monitoring for fetal distress is important but not the immediate priority when cord prolapse is a concern. Choice C, administering antibiotics, may be necessary but does not address the immediate risk of cord prolapse. Choice D, performing a vaginal exam, can increase the risk of infection and should be avoided until cord prolapse is ruled out.

Correct Answer: A

Rationale: The correct answer is A: Cervical dilation. Assessing cervical dilation is crucial as it indicates the progress of labor and readiness for pushing. The nurse needs to determine if the woman is fully dilated to guide the timing of pushing. B: Fetal position is important but not the immediate priority when the woman is experiencing the urge to push. C: Fetal heart rate should be continually monitored during labor but is not the next assessment when the woman has the urge to push. D: Maternal blood pressure is important but not the immediate concern when the woman is ready to push.

Correct Answer: C

Rationale: The correct answer is C: Alcohol abuse. During adolescence, children of parents who have substance abuse issues, like alcohol, are at an increased risk of developing similar problems. This is due to genetic predisposition, environmental factors, and learned behavior. Children tend to model the behavior of their parents, and if they are exposed to alcohol abuse at a young age, they are more likely to engage in alcohol abuse themselves as they grow older. Incorrect choices: A: Hypertension - This choice is not directly related to the situation described and is not typically a risk factor associated with parental alcohol abuse. B: Diabetes - Similar to choice A, diabetes is not directly linked to parental alcohol abuse and is not a common risk factor during adolescence in this scenario. D: Intraventricular bleeding - This is a medical condition that is not typically influenced by parental alcohol abuse and is not a common risk factor during adolescence.