The nurse is caring for a client in the second stage of labor. What assessment indicates that birth is imminent?

Correct Answer: B

Rationale: In the context of pharmacology and the care of a client in the second stage of labor, the correct assessment indicating that birth is imminent is option B: "Fetal head is crowning." This is because crowning, which refers to the visible part of the baby's head at the vaginal opening, typically occurs just before birth is about to happen. This visual cue signifies that the baby is descending through the birth canal and delivery is imminent. Option A, "Cervix is dilated to 8 cm," is an important assessment indicating progress in labor but does not specifically indicate that birth is imminent. It shows the stage of dilation but not necessarily the exact timing of birth. Option C, "Contractions every 3-5 minutes," is a common pattern seen in the active phase of labor but does not provide a definitive indication that birth is about to happen in the immediate term. Option D, "Client reports back pain," is a vague symptom that can occur at various stages of labor and does not specifically signal that birth is imminent. In an educational context, understanding the nuances of labor assessments is crucial for nurses to provide appropriate care and support during childbirth. Recognizing the signs of imminent birth, such as crowning, helps nurses prepare for the delivery process and provide timely interventions if necessary. This knowledge is essential for ensuring the safety and well-being of both the mother and the newborn.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Check maternal blood pressure. When a client in labor receiving an epidural reports feeling lightheaded and nauseous, it could indicate hypotension, a common side effect of epidural anesthesia. Checking the maternal blood pressure is crucial to assess for hypotension, which can compromise both maternal and fetal well-being. Option A) Administer antiemetics as prescribed is incorrect because the priority is to address the potential hypotension first before treating the nausea. Option C) Increasing the oxytocin infusion rate is incorrect because the client is experiencing symptoms of hypotension, not related to the need for increased oxytocin. Option D) Encouraging the client to lie on her back is incorrect as this position can worsen hypotension. Educationally, understanding the potential side effects of epidural anesthesia, such as hypotension, is essential for nurses caring for laboring clients. Prompt assessment and intervention are crucial to ensure the safety of both the mother and the baby. Prioritizing interventions based on the client's condition and the potential risks involved is a fundamental aspect of maternal-newborn care.

Correct Answer: C

Rationale: In this scenario, the nurse's priority intervention should be option C: assess fetal heart rate and contraction pattern. This is the correct answer because when a client at 28 weeks' gestation reports regular uterine contractions, assessing the fetal heart rate and contraction pattern is crucial to determine the well-being of the fetus. Monitoring these parameters helps in evaluating fetal distress and the effectiveness of the contractions. It allows for timely intervention if there are signs of fetal compromise. Option A, administering tocolytic medication, is not the priority in this situation because before initiating tocolytic therapy, it is essential to assess the fetal status to determine if the contractions are causing any harm to the fetus. Performing a sterile vaginal examination (Option B) can introduce the risk of infection and should not be the immediate priority unless there are specific indications after assessing fetal well-being. Encouraging ambulation (Option D) may be helpful in some cases, but it is not the priority when the fetal well-being is in question. Educationally, this question highlights the importance of assessing fetal well-being in pregnant clients experiencing uterine contractions. It emphasizes critical thinking skills in prioritizing interventions based on the client's condition and the potential impact on fetal health. This rationale underscores the significance of accurate assessment and monitoring in maternal newborn care.

Correct Answer: B

Rationale: Headaches and nausea are common side effects of oral contraceptives. Choice A is incorrect because birth control pills typically decrease the menstrual flow. Choice C is not commonly reported with oral contraceptives, and many women report no change in libido. Choice D is incorrect because while oral contraceptives may slightly increase the risk of certain cancers, breast cancer risk is not significantly elevated compared to the general population.

Correct Answer: B

Rationale: When assisting a person desiring contraception, asking whether they have ever been pregnant is an important question because it helps the healthcare provider assess the individual's past reproductive history, including any pregnancies and potential complications. This information is important in determining the most suitable contraceptive options for the person, taking into account their previous experiences with pregnancy and childbirth. It can also help in evaluating the effectiveness of their past contraceptive methods and guide the selection of appropriate contraceptive counseling and options.