How often should the nurse assess the fetal heart using intermittent auscultation?

Correct Answer: D

Rationale: Intermittent auscultation is a method used to monitor the fetal heart rate during labor. It involves listening to the fetal heart rate at regular intervals to assess the well-being of the fetus. The correct answer is D: For 1 minute immediately after contractions. This is because immediately after contractions is when the fetal heart rate is most likely to show any signs of distress or changes in response to the stress of labor. By assessing the fetal heart rate for 1 minute after contractions, the nurse can quickly identify any potential issues and take appropriate action. Choice A: After every contraction is incorrect because assessing the fetal heart rate after every contraction would be too frequent and may not provide an accurate assessment of the fetal well-being. It is important to allow some time between contractions for the fetus to recover and for the nurse to observe any patterns or changes in the heart rate. Choice B: For 10 minutes every half hour is incorrect because it does not provide an immediate assessment of the fetal heart rate after contractions, which is crucial for detecting any changes in response to labor. Waiting 10 minutes every half hour may delay the identification of any potential issues and put the fetus at risk. Choice C: Periodically during the peak of contractions is incorrect because it does not specify a specific timing for assessing the fetal heart rate. It is important to have a clear and consistent protocol for monitoring the fetal heart rate to ensure timely detection of any problems. Assessing the heart rate only during the peak of contractions may miss important changes that occur immediately after contractions. In conclusion, assessing the fetal heart rate for 1 minute immediately after contractions is the most effective and appropriate method for using intermittent auscultation to monitor the well-being of the fetus during labor.

Correct Answer: B

Rationale: Option B is the correct answer because cervical dilation is a key indicator of labor progress. As labor progresses, the cervix dilates from closed (0 cm) to fully dilated (10 cm). In this case, the client's cervix has dilated from 2 to 4 cm, indicating that she is in active labor. This finding is a positive confirmation that labor has started and is progressing. Option A, contracting every 5 minutes, is not a definitive sign of labor. While regular contractions are a sign of labor, the frequency alone is not enough to confirm that the client is in active labor. The key factor to consider is cervical dilation. Option C, ruptured membranes, is also a sign of labor, but it is not a definitive confirmation on its own. Some clients may experience ruptured membranes without progressing into active labor. Therefore, this finding alone does not confirm that the client is in labor. Option D, fetal head engagement, is a sign that the baby is descending into the pelvis, but it is not a definitive confirmation of active labor. Fetal head engagement can occur before labor begins or during early labor. It is not a reliable indicator on its own to confirm that the client is in active labor.

Correct Answer: C

Rationale: Choice A is incorrect because the client's contractions being further apart (7 minutes) compared to earlier (5 minutes) indicates that labor is not progressing, as contractions should typically become closer together as labor intensifies. Choice B is incorrect because the client stating that she can talk through contractions easier after taking a walk suggests that the contractions may not be strong or frequent enough to indicate active labor. In active labor, contractions typically become more intense and difficult to talk through. Choice D is incorrect because the client mentioning tightening late afternoon and still feeling it after a nap does not necessarily indicate active labor. These symptoms could be attributed to Braxton Hicks contractions or false labor, which do not indicate that true labor has begun. Choice C is the correct answer because the client stating that contractions hurt more after taking a shower suggests that the contractions are becoming more intense and frequent, which are typical signs of active labor. The increase in pain and intensity of contractions after physical activity like a shower can indicate that labor is progressing.

Correct Answer: D

Rationale: Seeing the fetal head through the vaginal introitus indicates that the baby is descending through the birth canal and is close to being born. Therefore, the correct answer is D: "The baby is almost crowning." This statement accurately describes the position of the baby in relation to the birth process. Option A: "The baby's head is engaged." This statement refers to the baby's head being fixed in the mother's pelvis, not necessarily close to being born. While engagement is a positive sign of progress in labor, it does not indicate that the baby is almost crowning. Option B: "The baby is floating." This statement suggests that the baby is not yet engaged in the pelvis and is still floating freely. This is an incorrect statement as seeing the fetal head through the vaginal introitus indicates the baby is well descended and not floating. Option C: "The baby is at the ischial spines." This statement refers to the baby being at the level of the ischial spines in the pelvis. While this is a common landmark used to assess fetal descent, it does not necessarily mean that the baby is almost crowning. Seeing the fetal head through the vaginal introitus indicates the baby is further along in the birth process. In conclusion, the correct answer is D because it accurately describes the baby's position in relation to the birth process when the fetal head is seen through the vaginal introitus.

Correct Answer: B

Rationale: Option B is the correct answer because it acknowledges the client's feelings as normal during early pregnancy. It is essential for the nurse to validate the client's emotions and provide reassurance that it is common to have mixed feelings about pregnancy, especially during the first trimester. By normalizing the client's feelings, the nurse can establish a trusting and supportive relationship, which is crucial for effective communication and care. Option A is incorrect because it jumps to informing the provider without first addressing the client's feelings directly. While it is important to involve the provider if necessary, the immediate focus should be on addressing the client's emotions and providing support. Option C is incorrect because it dismisses the client's concerns and puts pressure on them to feel a certain way about their pregnancy. It is not helpful or therapeutic to tell the client how they should be feeling, as this can invalidate their emotions and create additional stress. Option D is incorrect because it assumes that the client needs counseling without first exploring their feelings and offering support. While counseling may be beneficial for some clients, it is important to first address the client's emotions and validate their experiences before making such a recommendation.