A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude?

Correct Answer: B

Rationale: The correct answer is B: The woman is about to deliver the placenta. After childbirth, it is normal for the placenta to be delivered within 30 minutes to an hour. In this scenario, the lengthening of the umbilical cord and the gush of blood suggest that the placenta is detaching from the uterine wall and is about to be expelled. This is a normal physiological process that occurs after delivery. Choice A: The woman has an internal laceration. This choice is incorrect because there is no indication in the scenario that the woman has an internal laceration. The gush of blood and lengthening of the umbilical cord are more indicative of the placenta being delivered. Choice C: The woman has an atonic uterus. This choice is incorrect because an atonic uterus refers to a uterus that is not contracting effectively after delivery, leading to excessive bleeding. In this case, the woman is experiencing a normal process of delivering the placenta, rather than a problem with uterine contractions. Choice D: The woman is ready to expel the cord bloods. This choice is incorrect because the scenario describes the lengthening of the umbilical cord, which is a sign that the placenta is detaching and about to be expelled, not the cord blood itself. The focus should be on the delivery of the placenta, not the cord blood. In conclusion, the nurse should conclude that the woman is about to deliver the placenta based on the signs of a gush of blood and lengthening of the umbilical cord. This is a normal part of the postpartum process and does not indicate any complications at this time.

Correct Answer: C

Rationale: After identifying that the woman is in the second stage of labor with a station of 2 and a baseline fetal heart rate of 130 with no decelerations, the appropriate nursing action is to delay pushing until the baby descends further and the mother has a strong urge to push (Choice C). This is because pushing prematurely can lead to ineffective pushing efforts, exhaustion, and increased risk of maternal and fetal complications. Waiting for the baby to descend further allows for optimal positioning and engagement of the fetal head in the pelvis, leading to more effective pushing and a smoother delivery process. Choice A is incorrect because coaching the woman to hold her breath and push 3 to 4 times with each contraction can lead to ineffective pushing efforts and decreased oxygenation to both the mother and the fetus. This can result in maternal exhaustion and fetal distress. Choice B is incorrect because administering oxygen via face mask at 8 to 10 liters per minute is not indicated in this scenario. The baseline fetal heart rate is normal and there are no signs of fetal distress requiring oxygen supplementation at this time. Choice D is incorrect because placing the woman on her side and assessing her oxygen saturation is not the most appropriate action in this situation. The focus should be on optimizing the pushing stage of labor to ensure a safe and effective delivery, rather than assessing oxygen saturation without any indication of respiratory distress.

Correct Answer: B

Rationale: Epidural administration can cause hypotension due to vasodilation, so it is crucial to prevent supine hypotension syndrome. Placing a wedge under the woman's side will help prevent aortocaval compression, which can lead to decreased blood return to the heart. This intervention promotes optimal fetal oxygenation and maternal perfusion. Assessing the woman's temperature (choice A) is not the priority in this scenario. While monitoring temperature is important, it is not as critical as preventing potential complications from the epidural. Placing a blanket roll under the woman's feet (choice C) is not the priority at this time. While this can provide comfort and prevent pressure ulcers, it does not address the immediate risk of aortocaval compression. Assessing the woman's pedal pulses (choice D) is not the priority after epidural administration. While neurovascular assessments are important, maintaining proper positioning to prevent hypotension takes precedence in this situation.

Correct Answer: A

Rationale: A: An Arabic woman is most likely to request that her head be kept covered throughout her hospitalization due to cultural and religious beliefs. In many Arab cultures, women cover their heads with a hijab or headscarf as a sign of modesty and respect. This practice is deeply rooted in Islamic teachings, which emphasize the importance of modesty in dress and behavior. Therefore, it is important for healthcare providers to respect the cultural and religious beliefs of their patients, including allowing an Arabic woman to keep her head covered if she wishes. B: A Chinese woman is less likely to request that her head be kept covered throughout her hospitalization. While some Chinese women may choose to wear a hat or head covering for personal reasons, it is not a common cultural or religious practice in Chinese culture. Therefore, it is less likely that a Chinese woman would request to keep her head covered in a hospital setting. C: A Russian woman is also less likely to request that her head be kept covered throughout her hospitalization. In Russian culture, there is no specific tradition or religious requirement for women to cover their heads in public or in healthcare settings. Therefore, it is unlikely that a Russian woman would request to keep her head covered during her hospitalization. D: A Greek woman is similarly less likely to request that her head be kept covered throughout her hospitalization. In Greek culture, there is no widespread practice of women covering their heads as a sign of modesty or religious observance. While some Greek women may choose to wear head coverings for personal reasons, it is not a common cultural or religious practice. Therefore, it is unlikely that a Greek woman would request to keep her head covered during her hospitalization.

Correct Answer: D

Rationale: Massaging the perineum with mineral oil prior to delivery is the correct intervention to decrease the possibility of a perineal laceration. This intervention helps to soften and lubricate the perineal tissues, making them more flexible and reducing the risk of tearing during delivery. Option A, assisting the woman into a squatting position, may actually increase the risk of perineal laceration. Squatting can increase pressure on the perineum, making it more likely to tear during delivery. Option B, advising the woman to push only when she feels the urge, is important for preventing unnecessary tearing but does not directly address the physical preparation of the perineum. Option C, encouraging the woman to push slowly and steadily, is also important for preventing perineal lacerations but does not address the physical preparation of the perineum like massaging with mineral oil does. In conclusion, massaging the perineum with mineral oil is the most effective intervention for decreasing the possibility of a perineal laceration during delivery as it directly prepares and lubricates the perineal tissues for stretching and reduces the risk of tearing.