If a woman's fundus is soft 30 minutes after birth, the nurse's first action should be to

Correct Answer: A

Rationale: The correct answer is A: massage the fundus. After childbirth, a soft fundus indicates uterine atony, which can lead to postpartum hemorrhage. Massaging the fundus helps stimulate contractions and reduce bleeding, promoting uterine tone. This intervention is crucial in preventing complications. Taking blood pressure (B) is important but not the priority in this situation. Increasing blood supply to the hands and feet (C) is not relevant to addressing uterine atony. Notifying the physician or nurse-midwife (D) can be done after initiating immediate intervention to manage the soft fundus.

Correct Answer: A

Rationale: The correct answer is A: Length of second-stage labor is 2 hours. This is applicable to the nursing diagnosis of "risk for injury" in a patient in labor because a prolonged second-stage labor can increase the risk of injury to both the mother and the baby. A prolonged second stage can lead to issues such as fetal distress, maternal exhaustion, and increased risk of instrumental delivery or cesarean section. Explanation for why the other choices are incorrect: B: Patient has received an epidural for pain control during the labor process - This choice does not directly address the risk for injury in labor. C: Patient is using breathing techniques during contractions to maximize pain relief - While breathing techniques can help with pain relief, it does not specifically address the risk for injury. D: Patient is receiving parenteral fluids during the course of labor to maintain hydration - While hydration is important during labor, it does not directly address the risk for injury.

Correct Answer: C

Rationale: The correct answer is C. Including test results ensuring that the fluid is not urine in the patient's record is crucial after a spontaneous rupture of membranes to confirm the presence of amniotic fluid, indicating the onset of labor. This information helps in assessing the progress of labor and ensuring the safety of both the mother and the fetus. A: Fetal heart rate is important but not directly related to the spontaneous rupture of membranes. It should be monitored separately. B: Pain level is subjective and can vary among individuals, not directly related to the rupture of membranes. D: The patient's understanding of the event is important for communication but does not provide essential clinical information related to the rupture of membranes.

Correct Answer: A

Rationale: After the baby's head is born, the immediate next step is the expulsion of the baby's body. This is because the expulsion maneuver refers to the delivery of the rest of the baby's body following the birth of the head. Restitution, internal rotation, and external rotation occur before the birth of the baby's head and are part of the cardinal movements of labor and birth. Restitution involves the realignment of the baby's head with their body after the head is born. Internal rotation refers to the baby's head turning to navigate through the birth canal. External rotation involves the baby's head turning back to its original position after delivery. So, the correct answer is A (Expulsion), as it directly follows the birth of the baby's head.

Correct Answer: D

Rationale: Rationale: 1. Past 42 weeks of gestation increases the risk of stillbirth. 2. Oxytocin can help initiate labor to reduce the risk. 3. Induction at this stage is considered safe and beneficial. 4. Other choices are not direct indications for oxytocin induction and may have different management strategies. Summary: - A: Multiple fetuses and polyhydramnios may require different approaches. - B: History of long labors may not necessarily indicate the need for oxytocin induction.