A woman in active labor demonstrates signs of prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?

Correct Answer: B

Rationale: When a woman in active labor exhibits signs of prolonged second stage, such as ineffective pushing efforts and slow fetal descent, one of the maternal conditions that should be considered is pelvic floor dysfunction. The pelvic floor muscles play a crucial role in supporting the uterus, bladder, and rectum. If these muscles are weak or dysfunctional, it can lead to difficulty in pushing effectively and impede the descent of the fetus through the birth canal. This can result in prolonged labor and increase the risk of complications for both the mother and the baby. Therefore, assessing for pelvic floor dysfunction is important in addressing the abnormal labor pattern and providing appropriate interventions to support the progress of labor.

Correct Answer: A

Rationale: Demonstrating breastfeeding positions that minimize pressure on the incision site should be the nursing intervention prioritized to address the client's concerns. This is important because it ensures that the client can breastfeed comfortably while also protecting the healing incision. By showing the client appropriate positions, such as the football hold or side-lying position, the nurse can help minimize discomfort and promote successful breastfeeding without compromising the cesarean incision's healing process. It is crucial to support the client in establishing a good latch and positioning to encourage proper milk transfer and bonding while being mindful of the incision site.

Correct Answer: C

Rationale: In a postpartum client complaining of persistent, heavy vaginal bleeding, the most appropriate nursing action is to assess vital signs and uterine tone. This is important to determine if the bleeding is within normal limits or if there is a potential postpartum hemorrhage (PPH) occurring. Monitoring vital signs can help identify signs of shock, while assessing uterine tone can help determine if the uterus is contracting effectively to control bleeding. Prompt assessment and early detection of PPH are crucial for effective management and prevention of complications. Encouraging increased fluid intake, applying a cold compress, and administering pain medication may be appropriate interventions in some situations, but assessing vital signs and uterine tone take priority in this scenario.

Correct Answer: C

Rationale: In a postpartum client who presents with severe abdominal pain, nausea, and vomiting, it is crucial to assess for signs of peritonitis or surgical abdomen. These signs may include rebound tenderness, guarding, rigidity, and fever. Peritonitis is a serious condition that may require immediate surgical intervention. Administering antiemetic medication, encouraging clear fluids, or providing a heating pad may not address the underlying cause of the symptoms and delay appropriate treatment. Assessing for signs of peritonitis or surgical abdomen is crucial for prompt identification and management of the client's condition.

Correct Answer: C

Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The client presenting with persistent, severe perineal pain and swelling, along with ecchymosis and tenderness of the perineum, could be indicative of complications such as a perineal hematoma. A perineal hematoma is a collection of blood in the perineal tissues and can be a serious postpartum complication requiring prompt medical attention. Therefore, it is crucial to alert the healthcare provider so that appropriate assessment, management, and treatment can be initiated promptly. Applying ice packs or encouraging the client to sit on a donut cushion may not be sufficient in this situation, and administering additional analgesic medication should be done only after the healthcare provider has assessed and determined the cause of the symptoms.