How does the nurse monitor for decreased perfusion?

Correct Answer: D

Rationale: Monitoring for decreased perfusion is crucial in assessing the adequacy of blood flow to tissues and organs. One way to assess perfusion is by monitoring urine output, making choice D the correct answer. Decreased perfusion can lead to decreased renal blood flow, resulting in a decrease in urine output. Monitoring 24-hour urine output can provide valuable information about the patient's renal function and overall perfusion status. Choice A, monitoring lochia, is not directly related to perfusion. Lochia refers to postpartum vaginal discharge and is more indicative of the healing process after childbirth rather than perfusion status. Choice B, measuring blood loss, can provide information about potential hemorrhage but does not directly assess perfusion. Although decreased blood volume can lead to decreased perfusion, monitoring blood loss alone does not provide a comprehensive assessment of perfusion status. Choice C, checking temperature, can be an indicator of infection or inflammation but does not directly assess perfusion. While infection or inflammation can impact perfusion, monitoring temperature alone is not a reliable method for assessing perfusion status.

Correct Answer: C

Rationale: Leopold's maneuvers are a series of four steps used to assess the position of the fetus in the uterus. Step 1: In the first step, the nurse determines which part of the fetus is located in the upper abdomen. This helps to identify the fetal presentation. Step 2: The second step involves palpating both sides of the uterus to determine which side the fetus's back is on. This helps to determine the fetal position. Step 3: In the third step, the nurse determines the location of the presenting part in the pelvis. This helps to determine the fetal station and engagement. Step 4: The final step involves palpating the lower abdomen to determine the position of the fetal back and limbs. This helps to determine the fetal lie. In this scenario, based on Leopold's maneuvers, if the nurse determines that the fetus's back is on the right side of the mother's abdomen and the small parts are felt on the left side, this indicates a longitudinal lie. A vertical lie means that the fetus's long axis is parallel to the mother's long axis. This is the correct answer. Choice A is incorrect because a transverse fetal position means that the fetus is lying horizontally across the mother's abdomen, which would not be determined by Leopold's maneuvers. Choice B is incorrect because the fetal presentation refers to the part of the fetus that is entering the maternal pelvis first. This is usually determined during the vaginal examination, not by Leopold's maneuvers. Choice D is incorrect because fetal attitude refers to the relationship of the fetal body parts to one another. It is not determined by Leopold's maneuvers, which focus on the position of the fetus in the uterus.

Correct Answer: A

Rationale: In the second stage of labor, the cervix is fully dilated at 10 centimeters and the baby is pushed through the birth canal. Option A, bulging perineum, is a sign that indicates progression into the second stage of labor. This occurs as the baby's head descends and puts pressure on the perineum, causing it to bulge outward. This is a clear indication that the second stage of labor has begun. Option B, increased bloody show, is not necessarily a sign of progression into the second stage of labor. Bloody show is a common sign of labor but it can occur in the first stage as well. It is caused by the release of the mucus plug that seals the cervix during pregnancy. Option C, spontaneous rupture of membranes, is also not a definitive sign of progression into the second stage of labor. This can happen at any point during labor and does not necessarily indicate the beginning of the second stage. Option D, inability to breathe through contractions, is not a sign of progression into the second stage of labor. While contractions can become more intense and frequent in the second stage, breathing techniques can still be used to help manage the pain and discomfort. In summary, the bulging perineum is the most reliable sign that indicates progression into the second stage of labor. Other signs mentioned in the options can occur at various points during labor and are not specific to the second stage.

Correct Answer: A

Rationale: The correct answer is A. Descent is progressing well. This is because the primipara is in active labor, 7 cm dilated, and at +3 station. At this point, the fetus is descending through the birth canal, which indicates progress in labor. The +3 station means that the fetal head is 3 cm below the ischial spines in the pelvis, which is a good sign that descent is occurring as expected. Therefore, it is important for the nurse to report that descent is progressing well. Choice B, fetal head is not yet engaged, is incorrect. The fact that the fetus is at +3 station indicates that the fetal head is engaged and descending into the pelvis. This is a positive sign of progress in labor. Choice C, vaginal delivery is imminent, is incorrect. While the primipara is at 7 cm dilated and at +3 station, it is not guaranteed that delivery is imminent. Labor can still take some time to progress further before delivery occurs. Choice D, external rotation is complete, is incorrect. External rotation occurs during the second stage of labor, not during active labor. At this point, the focus is on descent and dilation, rather than rotation of the fetus.

Correct Answer: C

Rationale: During the second stage of labor, the most appropriate breathing technique is to push down with an open glottis, which is option C. This technique is also known as the "pushing" stage of labor, where the mother actively works to push the baby through the birth canal. Option A, alternately pant and blow, is not the most appropriate technique during the second stage of labor. Panting and blowing are more commonly used during the first stage of labor to help manage contractions and stay relaxed. Option B, taking rhythmic, shallow breaths, is also not the most appropriate technique during the second stage of labor. This type of breathing may not provide enough power and force to effectively push the baby out. Option D, doing slow chest breathing, is not suitable for the second stage of labor either. Slow chest breathing is usually used for relaxation and pain management, rather than actively pushing during labor. In conclusion, pushing down with an open glottis is the most appropriate breathing technique during the second stage of labor because it helps the mother effectively push the baby through the birth canal.