What action can help a woman work with the pain of the first stage of labor?

Correct Answer: B

Rationale: Performing effleurage is the correct action to help a woman work with the pain of the first stage of labor. Effleurage is a massage technique involving gentle, rhythmic stroking movements on the skin, which can help distract the woman from the pain of contractions by providing a soothing sensation and promoting relaxation. This technique can also help the woman focus on her breathing and remain calm during labor, which can contribute to pain management. Lying in the lithotomy position (Choice A) is actually not recommended during labor as it can restrict blood flow to the uterus and baby, and make labor more difficult. This position can also increase the risk of perineal tearing. Practicing Kegel exercises (Choice C) can help strengthen the pelvic floor muscles, but it is not specifically helpful for managing the pain of the first stage of labor. Kegel exercises are more commonly recommended for improving bladder control and sexual function. Pushing with each contraction (Choice D) is generally reserved for the second stage of labor when the cervix is fully dilated. Pushing too early can lead to exhaustion and potentially cause the cervix to swell, prolonging labor. It is important for the woman to wait for the urge to push before beginning this stage.

Correct Answer: C

Rationale: Immediately after an amniotomy, which is the artificial rupture of the amniotic sac, the nurse's priority assessment should be the fetal heart rate (FHR). This is because amniotomy can cause changes in the fetal heart rate due to changes in the intrauterine environment. Monitoring the FHR helps to ensure the well-being of the fetus and detect any signs of fetal distress promptly. Option A, maternal blood pressure, is important to monitor during labor, but it is not the most immediate assessment after an amniotomy. Changes in maternal blood pressure may occur later and are not as directly impacted by the procedure. Option B, maternal pulse, is also important to monitor during labor, but it is not the most immediate assessment after an amniotomy. Changes in maternal pulse may occur later and are not as directly impacted by the procedure. Option D, fetal fibronectin level, is not typically assessed immediately after an amniotomy. Fetal fibronectin is a protein that may be tested to predict preterm labor, but it is not an immediate assessment that is needed after an amniotomy. Monitoring the FHR is more critical for immediate assessment in this situation.

Correct Answer: B

Rationale: Option B is the correct answer because cervical dilation is a key indicator of labor progress. As labor progresses, the cervix dilates from closed (0 cm) to fully dilated (10 cm). In this case, the client's cervix has dilated from 2 to 4 cm, indicating that she is in active labor. This finding is a positive confirmation that labor has started and is progressing. Option A, contracting every 5 minutes, is not a definitive sign of labor. While regular contractions are a sign of labor, the frequency alone is not enough to confirm that the client is in active labor. The key factor to consider is cervical dilation. Option C, ruptured membranes, is also a sign of labor, but it is not a definitive confirmation on its own. Some clients may experience ruptured membranes without progressing into active labor. Therefore, this finding alone does not confirm that the client is in labor. Option D, fetal head engagement, is a sign that the baby is descending into the pelvis, but it is not a definitive confirmation of active labor. Fetal head engagement can occur before labor begins or during early labor. It is not a reliable indicator on its own to confirm that the client is in active labor.

Correct Answer: C

Rationale: Choice A is incorrect because the client's contractions being further apart (7 minutes) compared to earlier (5 minutes) indicates that labor is not progressing, as contractions should typically become closer together as labor intensifies. Choice B is incorrect because the client stating that she can talk through contractions easier after taking a walk suggests that the contractions may not be strong or frequent enough to indicate active labor. In active labor, contractions typically become more intense and difficult to talk through. Choice D is incorrect because the client mentioning tightening late afternoon and still feeling it after a nap does not necessarily indicate active labor. These symptoms could be attributed to Braxton Hicks contractions or false labor, which do not indicate that true labor has begun. Choice C is the correct answer because the client stating that contractions hurt more after taking a shower suggests that the contractions are becoming more intense and frequent, which are typical signs of active labor. The increase in pain and intensity of contractions after physical activity like a shower can indicate that labor is progressing.

Correct Answer: D

Rationale: Seeing the fetal head through the vaginal introitus indicates that the baby is descending through the birth canal and is close to being born. Therefore, the correct answer is D: "The baby is almost crowning." This statement accurately describes the position of the baby in relation to the birth process. Option A: "The baby's head is engaged." This statement refers to the baby's head being fixed in the mother's pelvis, not necessarily close to being born. While engagement is a positive sign of progress in labor, it does not indicate that the baby is almost crowning. Option B: "The baby is floating." This statement suggests that the baby is not yet engaged in the pelvis and is still floating freely. This is an incorrect statement as seeing the fetal head through the vaginal introitus indicates the baby is well descended and not floating. Option C: "The baby is at the ischial spines." This statement refers to the baby being at the level of the ischial spines in the pelvis. While this is a common landmark used to assess fetal descent, it does not necessarily mean that the baby is almost crowning. Seeing the fetal head through the vaginal introitus indicates the baby is further along in the birth process. In conclusion, the correct answer is D because it accurately describes the baby's position in relation to the birth process when the fetal head is seen through the vaginal introitus.