The nurse should encourage the laboring client to begin pushing when

Correct Answer: C

Rationale: In the context of maternal and reproductive health, the correct answer is C) The cervix is completely dilated. This is because full cervical dilation (10 cm) indicates that the cervix is fully prepared for the pushing stage of labor. At this point, the client's body is physiologically ready for the second stage of labor, which involves pushing to facilitate the birth of the baby. Option A) There is only an anterior or posterior lip of cervix left is incorrect because the presence of even a small part of the cervix that is not fully dilated can obstruct the descent of the baby and hinder the progress of labor. Option B) The client describes the need to have a bowel movement is incorrect because the urge to push due to feeling like having a bowel movement may not necessarily indicate full cervical dilation and readiness for the pushing stage of labor. Option D) The cervix is completely effaced is incorrect because cervical effacement, which refers to the thinning of the cervix, is important for labor progress but not a direct indicator of the readiness to begin pushing. In an educational context, it is crucial for nurses to understand the significance of cervical dilation in guiding the management of laboring clients. Recognizing the signs of full dilation ensures that the pushing stage commences at the appropriate time, promoting effective labor progress and optimal maternal and fetal outcomes.

Correct Answer: C

Rationale: In this scenario, the correct intervention is to monitor bleeding from IV sites (Option C). This choice is appropriate because the client is experiencing dark red vaginal bleeding, which indicates a potential hemorrhage. Monitoring for bleeding from IV sites is crucial as it can help identify if the bleeding is generalized or localized, providing essential information for the healthcare team to manage the situation effectively. Assessing for cervical changes q1h (Option B) is not the priority in this case as the client's vaginal bleeding and uterine tone suggest a more urgent issue related to potential hemorrhage. Inserting an internal fetal monitor (Option A) or performing Leopold's maneuvers (Option D) are also not indicated at this time as the primary concern is addressing the maternal health status. From an educational perspective, this question highlights the importance of prioritizing interventions based on the client's immediate needs. Understanding the significance of assessing and managing maternal hemorrhage is critical for nurses working in labor and delivery units to ensure the safety and well-being of both the mother and the baby. By mastering these principles, nurses can provide high-quality care and potentially save lives in emergency situations.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Transition labor with contractions every 2 minutes, lasting 90 seconds each. This pattern indicates very frequent and prolonged contractions, which can lead to uterine hyperstimulation and potential fetal distress. Discontinuing the oxytocin infusion in this situation is crucial to prevent further complications and allow for adequate uterine relaxation. Option B) Early labor with contractions every 5 minutes, lasting 40 seconds each, represents a normal pattern for early labor and does not warrant discontinuation of oxytocin. Option C) Active labor with contractions every 31 minutes, lasting 60 seconds each, indicates inadequate contractions for progression and would not require stopping oxytocin. Option D) Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each, also represents a pattern of appropriate contractions for active labor and does not necessitate discontinuation of oxytocin. Educationally, understanding the appropriate management of oxytocin infusion in labor is essential for ensuring maternal and fetal well-being. Nurses must be able to recognize patterns of contractions that may indicate uterine hyperstimulation and take prompt action to prevent adverse outcomes. This rationale emphasizes the importance of monitoring labor progression and responding appropriately to deviations from normal patterns.

Correct Answer: A

Rationale: In the context of client teaching for gravid clients, the factor with the greatest influence on successful teaching is the client's readiness to learn (Option A). This is because a client's willingness and ability to engage with the information being presented significantly impact the effectiveness of the teaching process. When a client is motivated and open to learning, they are more likely to retain and apply the information provided by the maternity nurse. Clients who are ready to learn are more likely to ask questions, participate actively in discussions, and follow through with recommended practices, leading to better maternal and reproductive health outcomes. Regarding the other options: - Option B (The client's educational background) is less influential because regardless of a client's educational level, their readiness to learn can still vary. Education does not always correlate with a person's receptiveness to new information. - Option C (The order in which the information is presented) is important but not as critical as the client's readiness. While presentation order can impact comprehension, if the client is not receptive, the sequencing of information becomes less effective. - Option D (The extent to which the pregnancy was planned) may have some impact on the client's mindset and readiness to engage in learning, but it is not as directly related to the teaching process as the client's actual readiness to learn. In educational context, understanding and assessing the client's readiness to learn is fundamental for a maternity nurse to tailor their teaching strategies effectively. By recognizing and responding to the client's readiness, nurses can optimize the teaching process, promote client engagement, and ultimately enhance the client's maternal and reproductive health outcomes.

Correct Answer: B

Rationale: The most common neonatal birth trauma due to vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fracture clavicle should be suspected is an infant has limited use of the affected arm malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.