An infant is breastfeeding for the first time. Which statement by the client indicates that she understands how to prevent skin breakdown?

Correct Answer: B

Rationale: Inserting the finger into the baby's mouth before removing them from the breast is the correct answer because it helps break the suction created by the baby's latch. This prevents the baby from pulling away suddenly, which can cause damage to the mother's nipple and lead to skin breakdown. By breaking the suction gently with the finger, the baby can be detached from the breast without causing harm. Choice A, wearing waterproof pads inside the bra, does not directly address the issue of preventing skin breakdown from improper latch or detachment. While it may help with leakage, it does not prevent the actual cause of skin breakdown during breastfeeding. Choice C, breastfeeding every four hours, does not address the issue of proper latch and detachment techniques that are essential for preventing skin breakdown. It is more important to focus on the correct latch and detachment methods rather than the frequency of breastfeeding sessions. Choice D, alternating breasts at each feeding, also does not directly relate to preventing skin breakdown. While it is generally recommended to alternate breasts to ensure equal milk production, it does not address the immediate concern of preventing skin breakdown during the breastfeeding session. In conclusion, inserting the finger into the baby's mouth before removing them from the breast is the most effective way to prevent skin breakdown during breastfeeding by ensuring a gentle detachment without causing harm to the mother's nipple.

Correct Answer: B

Rationale: During the second stage of labor, the woman experiences strong contractions and an urge to push as the baby descends through the birth canal. Option A, assessing the fetal heart rate between contractions every 60 minutes, is incorrect because during the second stage of labor, fetal heart rate should be monitored continuously to ensure the well-being of the baby. Waiting 60 minutes between assessments could lead to missed signs of fetal distress. Option C, assessing the pulse and respirations of the mother every 5 minutes, is also incorrect. While it is essential to monitor the mother's vital signs, checking them every 5 minutes may not be necessary unless there are signs of distress or complications. Continuous monitoring is not typically required during the second stage of labor unless there are specific concerns. Option D, positioning the woman on her back with her knees on her chest, is not appropriate during the second stage of labor. This position, known as the lithotomy position, can actually impede the progress of labor by reducing the size of the pelvic outlet and increasing the risk of perineal trauma. It is more beneficial for the woman to be in an upright or semi-recumbent position that allows gravity to assist in the descent of the baby. Encouraging the woman to grunt during contractions, as stated in option B, is the correct action for the nurse to take during the second stage of labor. Grunting can help the woman focus her pushing efforts effectively, prevent her from pushing too forcefully, and conserve her energy for the duration of labor. This technique can also help prevent perineal trauma and promote a controlled delivery of the baby.

Correct Answer: B

Rationale: B: The nurse should provide further information to the client when she states, "I heard that for doctors to deliver babies safely, it is essential to have the mother's legs up in stirrups." This statement is incorrect because the use of leg stirrups during delivery is not necessary for all women, and it is not the only safe way to deliver a baby. It is important for the nurse to educate the client that there are various positions for giving birth, and the use of stirrups is not always required. Providing this information will help the client make informed decisions about her delivery. A: The client stating, "I am glad that deliveries can take place in a variety of places, including a Jacuzzi bathtub," does not require further information from the nurse. While water births in Jacuzzi bathtubs are an option for some women, it is essential for the nurse to ensure that the client has accurate information about the safety and appropriateness of this delivery method. C: When the client mentions, "During difficult deliveries it is sometimes necessary to put a woman's legs up in stirrups," the nurse does not need to provide further information. This statement acknowledges that there are situations where using leg stirrups may be necessary, such as during a difficult delivery. However, it is still important for the nurse to discuss other potential positions and options with the client. D: The client stating, "I heard that midwives often deliver their patients either in the side-lying or squatting position," does not require further information from the nurse. This statement demonstrates that the client is aware of alternative birthing positions besides using leg stirrups. It is valuable for the nurse to affirm this knowledge and provide additional information if needed to support the client's understanding of birthing positions.

Correct Answer: B

Rationale: During the transition phase of labor, which is the most intense phase before pushing, the woman is likely to experience significant pain and discomfort due to strong and frequent contractions. Choice B, "I can't stand this pain any longer," is the correct answer because it reflects the expected response during this phase. The woman is likely to express feelings of being overwhelmed by the pain and may find it difficult to cope. Choice A, "I am so excited to be in labor," is incorrect because the transition phase is typically not a time of excitement but rather a time of intense focus and discomfort as the body prepares for the final stage of labor. Choice C, "I need ice chips because I'm so hot," is incorrect because the need for ice chips to cool down is not typically associated with the transition phase of labor. The focus during this phase is more on managing the pain and preparing for delivery. Choice D, "I have to push the baby out right now," is incorrect because the urge to push usually comes later in the labor process during the second stage, after the cervix is fully dilated. In the transition phase, the woman may feel an intense pressure but may not be fully dilated yet, so pushing prematurely can be harmful. In conclusion, the correct answer is B because it accurately reflects the expected experience of intense pain and discomfort during the transition phase of labor.

Correct Answer: A

Rationale: During the latent phase of labor, contractions are typically mild to moderate in intensity and occur at regular intervals. Choice A is correct because if the woman is able to talk and laugh during contractions, it indicates that her contractions are not yet intense or close enough together to signify active labor. This aligns with the characteristics of the latent phase. Choice B is incorrect because complaining about severe back labor is more indicative of active labor, where contractions are stronger and more frequent. This symptom is not typically associated with the latent phase of labor. Choice C is incorrect because performing effleurage (light circular stroking of the abdomen) during a contraction is a coping mechanism often used in active labor to help manage pain. In the latent phase, contractions are usually not intense enough to necessitate coping techniques like effleurage. Choice D is incorrect because the urge to defecate is more commonly associated with the later stages of labor as the baby descends and puts pressure on the rectum. In the latent phase, the woman is typically still able to walk around and may not yet feel the urge to bear down. In summary, the ability to talk and laugh during contractions is a key characteristic of the latent phase of labor, making choice A the correct answer. Choices B, C, and D are all more indicative of active labor or the later stages of labor, making them incorrect in this context.