A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse

Correct Answer: B

Rationale: The sudden urge to push along with the advanced cervical dilation, effacement, and station indicates that the client is likely in the second stage of labor, which is the stage of active pushing. When a woman feels the urge to push, it is essential to assess for the crowning of the fetal head at the perineum as this indicates that the baby is descending and will soon be born. This assessment helps the nurse determine the appropriate actions to take next in assisting the delivery process. Waiting for signs of crowning before guiding the client to push can prevent potential complications related to a rapid birth and help facilitate a more controlled delivery process.

Correct Answer: B

Rationale: Infants of diabetic mothers are at increased risk for developing respiratory distress syndrome due to factors such as prematurity, intrauterine stress, and macrosomia (large birth weight). Additionally, babies born to mothers with diabetes may have delayed lung maturation, resulting in decreased surfactant production and increased risk of respiratory complications. Therefore, it is crucial for the nurse to monitor the infant for signs of respiratory distress, such as tachypnea, grunting, retractions, and cyanosis, and provide necessary interventions promptly.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.