A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for?

Correct Answer: B

Rationale: During the third stage of labor, the nurse should be assessing for signs of placental separation and expulsion. Choice B, "Uterus rising in the abdomen and feeling globular," is the correct answer because this is a classic sign that the placenta is detaching from the uterine wall. As the uterus rises, it indicates that the placenta is being expelled. This assessment is crucial to ensure that the placenta is delivered in its entirety and to prevent complications such as postpartum hemorrhage. Choice A, "Fetal heart assessment after each contraction," is incorrect for the third stage of labor. Fetal heart assessment is more relevant during the first and second stages of labor when monitoring fetal well-being during contractions. In the third stage, the focus shifts to the delivery of the placenta and maternal recovery. Choice C, "Rapid cervical dilation to ten centimeters," is also incorrect during the third stage of labor. Cervical dilation typically occurs during the first stage of labor, not the third stage. By this stage, the cervix should be fully dilated, and the focus should be on the delivery of the placenta. Choice D, "Maternal complaints of intense rectal pressure," is a common sign of fetal descent during the second stage of labor, not the third stage. This sensation occurs as the baby moves down the birth canal and is a signal for the mother to start pushing. In the third stage, the mother may experience mild contractions as the placenta separates, but intense rectal pressure is not typically associated with this stage. In summary, during the third stage of labor, the nurse should assess for the rising of the uterus in the abdomen, indicating placental separation and expulsion. Fetal heart assessment, cervical dilation, and complaints of rectal pressure are not typically assessed during this stage and are more relevant to earlier stages of labor.

Correct Answer: A

Rationale: The correct position for a woman to be in when inserting an epidural catheter is the fetal position. This position allows for easier access to the epidural space in the lower back. The fetal position involves the patient curling up on their side with their knees drawn up towards their chest. This position helps to widen the spaces between the vertebrae, making it easier for the anesthesiologist to insert the catheter into the epidural space. Option B, the lithotomy position, is not appropriate for inserting an epidural catheter. The lithotomy position involves the patient lying on their back with their legs elevated and spread apart. This position is typically used for gynecological exams and procedures, not for epidural placement. Option C, the Trendelenburg position, is also not suitable for inserting an epidural catheter. The Trendelenburg position involves the patient lying flat on their back with the legs elevated higher than the head. This position is used to improve venous return to the heart and is not necessary or beneficial for epidural placement. Option D, the lateral recumbent position, is not the ideal position for inserting an epidural catheter either. The lateral recumbent position involves the patient lying on their side with their top leg straight and bottom leg bent. While this position may be used for certain medical procedures, it does not provide the optimal access to the epidural space for catheter insertion.

Correct Answer: B

Rationale: The correct answer is B: Fetal heart acceleration. During a fetal scalp stimulation test, the practitioner will apply pressure to the fetal scalp to stimulate the baby. A normal response to this stimulation is an acceleration in the fetal heart rate. This is because the stimulation causes an increase in sympathetic nervous system activity, leading to an increase in heart rate. This is a reassuring sign of fetal well-being as it indicates that the baby is responding appropriately to stimuli. Now, let's discuss why the other choices are incorrect: A: Spontaneous fetal movement. While fetal movement is a sign of fetal well-being, the fetal scalp stimulation test specifically looks for a response in the fetal heart rate, not fetal movement. Therefore, this choice is not the expected response during this test. C: Increase in fetal heart variability. Fetal heart rate variability is a measure of the fluctuations in the fetal heart rate over time. While variability is a positive sign of fetal well-being, it is not the expected response during a fetal scalp stimulation test. The test is specifically looking for a change in the fetal heart rate in response to stimulation, not an increase in variability. D: Resolution of late decelerations. Late decelerations are a concerning fetal heart rate pattern that indicates uteroplacental insufficiency. The fetal scalp stimulation test is not designed to resolve late decelerations. It is used to assess fetal well-being by evaluating the fetal heart rate response to stimulation. In conclusion, the correct response to a fetal scalp stimulation test is an acceleration in the fetal heart rate. This indicates that the baby is responding appropriately to stimulation and is a reassuring sign of fetal well-being.

Correct Answer: C

Rationale: Choice A is incorrect because encouraging the father to hold his partner's hand during labor is not specifically related to the patient's religious or cultural beliefs as an Orthodox Jewish woman. While emotional support is important during labor, this choice does not address any specific cultural needs of the patient. Choice B is incorrect because asking the woman if she would like to speak with her priest assumes that the patient is Catholic or another faith that has priests. In this case, the patient is identified as being Orthodox Jewish, so it would not be appropriate to offer the services of a priest, as this does not align with her religious beliefs. Choice D is incorrect because placing an order for the woman's postpartum vegetarian diet assumes that all Orthodox Jewish individuals follow a vegetarian diet, which is not necessarily the case. While some may choose to follow a vegetarian diet for religious or personal reasons, it is not a universal practice among Orthodox Jewish individuals. Choice C is the correct answer because providing the woman with a long-sleeved hospital gown aligns with the modesty and privacy guidelines of Orthodox Jewish women. Modesty is an important aspect of Orthodox Jewish culture, and providing appropriate attire that respects this aspect of her beliefs is an important part of culturally competent care.

Correct Answer: A

Rationale: To calculate the drip rate for the IV infusion, you first need to determine the total volume of fluid to be infused per hour. The order is to infuse 1000 cc of D5 1/2 NS at a rate of 150 cc/hr. Next, you need to convert the volume to drops per minute using the drop factor of 10 gtt/cc. First, calculate the total volume to be infused per hour: 1000 cc ÷ 150 cc/hr = 6.67 hours Next, convert the volume to drops per minute: 1000 cc × 10 gtt/cc = 10,000 gtt 10,000 gtt ÷ 60 min = 166.67 gtt/min Therefore, the correct drip rate is 167 gtt/min (rounded to the nearest whole number), which corresponds to answer choice A. Choices B, C, and D are marked as N/A because they do not provide a numerical value for the drip rate. These choices are incorrect as they do not offer a solution to the question posed. The correct answer, choice A, is based on accurate calculations and proper conversion of units to determine the appropriate drip rate for the IV infusion.