The nurse is explaining to the nursing student that amniotic fluid helps the fetus to maintain a normal body temperature and: (Select all that apply)

Correct Answer: C

Rationale: Amniotic fluid plays a crucial role in the development and protection of the fetus during pregnancy. One of the key functions of amniotic fluid is to promote the adherence of fetal lung tissue to the chest wall. This is important because it helps the lungs to properly develop and function after birth. Option A is incorrect because while amniotic fluid does provide some protection and cushioning for the fetus, it does not serve as a primary source of nutrition. The fetus receives its nutrients through the placenta. Option B is incorrect because amniotic fluid does not directly influence the growth of the fetal limbs. Limb growth is primarily determined by genetic factors and the fetus's overall development. Option D is incorrect because while amniotic fluid can help the fetus to develop muscle tone through movement and exercise in the womb, it is not the primary factor in promoting muscle tone development. Muscle tone development is influenced by genetic factors and the fetus's overall health and development.

Correct Answer: D

Rationale: Option A is incorrect because it dismisses the client's feelings as normal without acknowledging the need for support or understanding. While it is true that new moms may cry frequently, it is important to address the client's specific feelings of being overwhelmed and sad. Option B is incorrect because it inaccurately states that postpartum blues can last for 3 months or longer. Postpartum blues typically resolve within the first two weeks after delivery and are considered a normal part of the postpartum period. Prolonged symptoms may indicate a more serious condition, such as postpartum depression. Option C is incorrect because it jumps to the conclusion that the client may benefit from medication without further assessment or discussion with a healthcare provider. While postpartum depression is common and can benefit from medication, it is important to first assess the severity of the client's symptoms and explore other support options before recommending medication. Option D is the correct answer because it acknowledges the temporary nature of postpartum blues and the normal changes in mood that new mothers may experience. By reassuring the significant other that the client's feelings are common and temporary, it helps normalize the client's experience and encourages support and understanding rather than immediate intervention. It is important to provide emotional support, validation, and resources for the client to manage her feelings during this challenging time.

Correct Answer: B

Rationale: Inserting the finger into the baby's mouth before removing them from the breast is the correct answer because it helps break the suction created by the baby's latch. This prevents the baby from pulling away suddenly, which can cause damage to the mother's nipple and lead to skin breakdown. By breaking the suction gently with the finger, the baby can be detached from the breast without causing harm. Choice A, wearing waterproof pads inside the bra, does not directly address the issue of preventing skin breakdown from improper latch or detachment. While it may help with leakage, it does not prevent the actual cause of skin breakdown during breastfeeding. Choice C, breastfeeding every four hours, does not address the issue of proper latch and detachment techniques that are essential for preventing skin breakdown. It is more important to focus on the correct latch and detachment methods rather than the frequency of breastfeeding sessions. Choice D, alternating breasts at each feeding, also does not directly relate to preventing skin breakdown. While it is generally recommended to alternate breasts to ensure equal milk production, it does not address the immediate concern of preventing skin breakdown during the breastfeeding session. In conclusion, inserting the finger into the baby's mouth before removing them from the breast is the most effective way to prevent skin breakdown during breastfeeding by ensuring a gentle detachment without causing harm to the mother's nipple.

Correct Answer: C

Rationale: C: Comfort level about self-insertion of the ring every 3 weeks. The correct answer is C because the vaginal ring is a form of birth control that is inserted into the vagina and left in place for three weeks before being removed for a week-long break. This method requires self-insertion, so it is important for the nurse to assess the woman's comfort level with this aspect of the contraceptive method. This ensures that the woman is able to properly use the vaginal ring and adhere to the recommended schedule for insertion and removal. A: Ability to remember to insert the device every morning. This statement is incorrect because the vaginal ring is not inserted daily like some other forms of birth control. The vaginal ring is typically inserted once every three weeks and removed after that period, which is a different schedule compared to daily insertion. Therefore, the woman's ability to remember to insert the device every morning is not relevant to using the vaginal ring. B: Feelings about having to insert the device before sexual intercourse. This statement is incorrect because the vaginal ring does not need to be inserted immediately before sexual intercourse. The vaginal ring is inserted once every three weeks and does not require insertion right before sexual activity. Therefore, the woman's feelings about inserting the device before intercourse are not relevant to using the vaginal ring. D: Ability to return to the clinic once a month for reinsertion. This statement is incorrect because the vaginal ring does not need to be reinserted monthly. The vaginal ring is typically inserted once every three weeks by the woman herself and does not require monthly reinsertion at a clinic. Therefore, the woman's ability to return to the clinic once a month for reinsertion is not relevant to using the vaginal ring.

Correct Answer: B

Rationale: During the second stage of labor, the woman experiences strong contractions and an urge to push as the baby descends through the birth canal. Option A, assessing the fetal heart rate between contractions every 60 minutes, is incorrect because during the second stage of labor, fetal heart rate should be monitored continuously to ensure the well-being of the baby. Waiting 60 minutes between assessments could lead to missed signs of fetal distress. Option C, assessing the pulse and respirations of the mother every 5 minutes, is also incorrect. While it is essential to monitor the mother's vital signs, checking them every 5 minutes may not be necessary unless there are signs of distress or complications. Continuous monitoring is not typically required during the second stage of labor unless there are specific concerns. Option D, positioning the woman on her back with her knees on her chest, is not appropriate during the second stage of labor. This position, known as the lithotomy position, can actually impede the progress of labor by reducing the size of the pelvic outlet and increasing the risk of perineal trauma. It is more beneficial for the woman to be in an upright or semi-recumbent position that allows gravity to assist in the descent of the baby. Encouraging the woman to grunt during contractions, as stated in option B, is the correct action for the nurse to take during the second stage of labor. Grunting can help the woman focus her pushing efforts effectively, prevent her from pushing too forcefully, and conserve her energy for the duration of labor. This technique can also help prevent perineal trauma and promote a controlled delivery of the baby.