The nurse is caring for an Orthodox Jewish woman in labor. It would be appropriate for the nurse to include which of the following in the plan of care?

Correct Answer: C

Rationale: Choice A is incorrect because encouraging the father to hold his partner's hand during labor is not specifically related to the patient's religious or cultural beliefs as an Orthodox Jewish woman. While emotional support is important during labor, this choice does not address any specific cultural needs of the patient. Choice B is incorrect because asking the woman if she would like to speak with her priest assumes that the patient is Catholic or another faith that has priests. In this case, the patient is identified as being Orthodox Jewish, so it would not be appropriate to offer the services of a priest, as this does not align with her religious beliefs. Choice D is incorrect because placing an order for the woman's postpartum vegetarian diet assumes that all Orthodox Jewish individuals follow a vegetarian diet, which is not necessarily the case. While some may choose to follow a vegetarian diet for religious or personal reasons, it is not a universal practice among Orthodox Jewish individuals. Choice C is the correct answer because providing the woman with a long-sleeved hospital gown aligns with the modesty and privacy guidelines of Orthodox Jewish women. Modesty is an important aspect of Orthodox Jewish culture, and providing appropriate attire that respects this aspect of her beliefs is an important part of culturally competent care.

Correct Answer: A

Rationale: Before proceeding with a physical assessment, the nurse should check the client's weight gain in the prenatal record. This is important because weight gain during pregnancy is a significant indicator of the health of both the mother and the developing fetus. Monitoring weight gain helps healthcare providers assess if the mother is gaining an appropriate amount of weight for a healthy pregnancy and if there are any potential complications such as gestational diabetes or preeclampsia. Choice B, the client's ethnicity and religion, is incorrect because while cultural considerations are important in providing individualized care, they do not directly impact the physical assessment process. Choice C, the client's age, is also incorrect as age alone does not provide enough information to determine the client's health status during pregnancy. Choice D, the type of insurance the woman has, is incorrect because insurance status is not a determining factor in conducting a physical assessment. While insurance coverage may impact the client's access to healthcare services, it does not directly influence the physical assessment process. Monitoring weight gain is essential for assessing the health and well-being of both the mother and the developing fetus during pregnancy.

Correct Answer: C

Rationale: If a hard round mass is felt in the fundal area and a soft round mass is felt above the symphysis, the nurse can conclude that the fetal position is in a vertical lie. This is because the hard round mass in the fundal area indicates the head of the fetus, which is the presenting part in a vertical lie. The soft round mass above the symphysis is likely the buttocks or back of the fetus, further supporting the vertical lie position. Choice A, transverse position, is incorrect because in a transverse position, the fetus would be lying sideways across the abdomen, not with a hard round mass in the fundal area and a soft round mass above the symphysis. Choice B, vertex presentation, is also incorrect because a vertex presentation refers to the head of the fetus being the presenting part, which would not explain the soft round mass felt above the symphysis. Choice D, attitude is difficult to determine, is not the correct answer because based on the description provided, the nurse can actually make a conclusion about the fetal position being in a vertical lie based on the different characteristics of the masses felt in the fundal area and above the symphysis.

Correct Answer: A

Rationale: During the second stage of labor, the cervix is fully dilated, and the baby is pushed out through the birth canal. A bulging perineum is the correct indication of progression to the second stage of labor. This occurs when the baby's head begins to crown and is visible at the vaginal opening. This visual sign shows that the baby is descending and moving through the birth canal, indicating that the second stage of labor has begun. An increase in bloody show, choice B, is a sign that labor is progressing, but it does not specifically indicate the transition to the second stage. Bloody show is a mixture of blood and mucus that is released as the cervix begins to dilate and efface during early labor. Rupture of membranes, choice C, typically occurs in the first stage of labor when the amniotic sac breaks, releasing amniotic fluid. While this can happen at any point during labor, it is not a definitive sign of progression to the second stage. A strong urge to push, choice D, is a common sensation during the second stage of labor when the cervix is fully dilated. However, the urge to push alone is not a reliable indicator of progression to the second stage, as it can also be present in the later stages of the first stage of labor. The bulging perineum is a more concrete and visual indication that the second stage has begun.

Correct Answer: A

Rationale: A presenting part at -3 station indicates that the fetal head is still relatively high in the pelvis and has not descended well into the birth canal. Choice B, stating that the fetal head is not engaged, is incorrect because the term "engagement" refers to the widest part of the presenting part (usually the biparietal diameter of the fetal head) passing through the pelvic inlet. -3 station would indicate that the head has not yet descended to the level of the ischial spines, which is typically considered engaged. Choice C, suggesting that the woman is close to delivery, is also incorrect. Typically, the station of the presenting part is measured in relation to the ischial spines, with 0 station being at the level of the spines. Negative numbers indicate that the presenting part is above the spines, while positive numbers indicate that it is below. -3 station is relatively high in the pelvis, so the woman is not close to delivery. Choice D, stating that external rotation has occurred, is also incorrect. External rotation typically occurs after the birth of the baby, not when the presenting part is at -3 station. Overall, a presenting part at -3 station indicates that descent is not progressing well and further descent is needed before the woman is likely to deliver.