The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time?

Correct Answer: C

Rationale: The correct answer is C: Report the fetal heart rate to the physician or nurse-midwife immediately. A fetal heart rate of 152 bpm is within the normal range for a fetus, but it is essential to communicate any findings to the healthcare provider for further assessment and monitoring. This step ensures the safety and well-being of both the mother and the fetus by allowing the healthcare provider to determine if any additional actions are necessary. Incorrect choices: A: Inform the mother that the fetal heart rate is normal - While the heart rate may be normal, it is crucial to involve the healthcare provider for proper evaluation. B: Reassess the fetal heart rate in 5 minutes because the rate is too high - 152 bpm is not considered too high, and immediate reporting to the healthcare provider is necessary. D: Suggest to the mother that she is going to have a boy because the heart rate is fast - Fetal heart rate is not a reliable indicator of the baby's gender, and this

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: C

Rationale: The correct answer is C: Document this evidence of normal early maternal-infant attachment behavior. This is the correct action because the mother's behavior of touching her infant with her fingertips and talking to him softly in high-pitched tones is indicative of normal maternal-infant attachment. This behavior shows that the mother is engaging with her infant in a positive and nurturing way, which is crucial for bonding and attachment. It is important for the nurse to document this behavior as it reflects a healthy interaction between the mother and her newborn. Other choices are incorrect: A: Request a social service consult for psychosocial support - This choice is not necessary as the mother's behavior indicates normal attachment and does not suggest a need for psychosocial support at this time. B: Observe for other signs that the mother may not be accepting of the infant - This choice is unnecessary as the mother's current behavior demonstrates acceptance and attachment towards her infant. D: Determine whether the mother is too fatigued to interact normally

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.