What assessments should the nurse perform to report the client's status? Select all that apply.

Correct Answer: C

Rationale: The correct answer is C: Contraction stress test. When assessing a client's status during labor, it is essential for the nurse to perform a contraction stress test. This test involves monitoring the client's contractions to assess their frequency, duration, and strength. By analyzing the contraction pattern, the nurse can determine the progress of labor and the well-being of the fetus. This information is crucial in identifying any potential complications that may arise during labor and delivery. Option A, Fetal heart rate, is also an important assessment to perform during labor. Monitoring the fetal heart rate provides valuable information about the baby's well-being and can help identify signs of distress. However, this assessment alone may not provide a comprehensive picture of the client's status, which is why option C is the better choice. Option B, Contraction pattern, is closely related to the correct answer. While monitoring the contraction pattern is important, it is not enough on its own to fully assess the client's status. The contraction stress test provides a more detailed assessment of the contractions and their impact on the fetus. Option D, Vital signs, is also an essential assessment to perform during labor. Monitoring the client's vital signs, such as blood pressure and temperature, can help identify any signs of infection or other complications. However, vital signs alone may not provide enough information to accurately assess the client's status during labor, making option C the most appropriate choice for this question.

Correct Answer: C

Rationale: When determining the fetal position, the nurse should place the fetoscope in the left lower quadrant (LLQ) to hear the fetal heartbeat for LOA positioning. This is because the fetal back is typically located on the left side of the mother's abdomen in the LOA (Left Occiput Anterior) position. Placing the fetoscope in the LLQ allows the nurse to listen directly over the fetal back, where the heartbeat is most easily heard. Option A: Placing the fetoscope in the left upper quadrant (LUQ) would not be the correct choice for LOA positioning. This area is farther away from the fetal back and may result in difficulty hearing the fetal heartbeat clearly. Option B: Placing the fetoscope in the right upper quadrant (RUQ) would also not be the correct choice for LOA positioning. In the LOA position, the fetal back is located on the left side of the mother's abdomen, so placing the fetoscope on the right side would not be effective in capturing the fetal heartbeat. Option D: Placing the fetoscope in the right lower quadrant (RLQ) is not the correct choice for LOA positioning. The fetal back is typically located on the left side of the mother's abdomen in the LOA position, so placing the fetoscope on the right side would not be ideal for hearing the fetal heartbeat clearly. In conclusion, placing the fetoscope in the left lower quadrant is the correct choice for hearing the fetal heartbeat in LOA positioning as it allows the nurse to listen directly over the fetal back where the heartbeat is most easily heard.

Correct Answer: C

Rationale: Breathing and relaxation exercises are taught in childbirth classes primarily to help break the fear-tension-pain cycle. This cycle occurs when a woman becomes anxious about labor and delivery, which leads to tension in her body, resulting in increased pain during contractions. By learning and practicing breathing and relaxation techniques, mothers can reduce their anxiety levels, which in turn helps to decrease tension and ultimately lower pain levels during labor. Option A, "Mothers refrain from yelling," is incorrect because the primary purpose of breathing and relaxation exercises is not to control vocalization but rather to manage pain and anxiety during childbirth. While these exercises may help mothers stay calm and focused, their main goal is not to prevent yelling. Option B, "Breathing exercises are less exhausting," is also incorrect because the main reason for teaching these exercises is not to reduce physical exhaustion. While proper breathing techniques can help conserve energy during labor, the primary goal is to manage pain and anxiety, not solely to lessen physical fatigue. Option D, "They promote maternal-newborn bonding," is not the primary rationale for teaching breathing and relaxation exercises in childbirth classes. While these exercises can certainly help mothers feel more connected to their newborns during the birthing process, their main purpose is to assist women in managing the physical and emotional challenges of labor. In conclusion, the correct answer is C because the primary rationale for teaching breathing and relaxation exercises in childbirth classes is to break the fear-tension-pain cycle, which can help mothers cope with labor more effectively.

Correct Answer: D

Rationale: Slow chest breathing is the most therapeutic breathing technique for the latent phase of labor for several reasons. During this phase, contractions are typically mild and infrequent, so it is important to conserve energy and remain calm. Slow chest breathing helps to achieve this by promoting relaxation and reducing anxiety. This technique involves taking slow, deep breaths in through the nose and out through the mouth, focusing on expanding the chest and diaphragm. Alternately panting and blowing (choice A) may be too fast and intense for the latent phase of labor, potentially causing hyperventilation and increased anxiety. Rapid, deep breathing (choice B) may also lead to hyperventilation and can be too taxing on the body during mild contractions. Grunting and pushing with contractions (choice C) should be reserved for the active phase of labor when the cervix is more dilated and contractions are stronger. In contrast, slow chest breathing (choice D) is a gentle and effective technique that helps women manage pain and discomfort during the latent phase of labor without expending unnecessary energy. It allows for better oxygenation and relaxation, which can help progress labor in a calm and controlled manner. By focusing on slow chest breathing, women can conserve their strength for the more intense stages of labor while still managing discomfort effectively.

Correct Answer: B

Rationale: In late labor, it is crucial for the nurse to evaluate the progress of labor first before taking any action. This is because the urge to move bowels can be a sign of fetal descent and impending birth. By evaluating the progress of labor, the nurse can determine if the client is fully dilated and if the baby is descending properly, which are essential factors for successful delivery. Option A, offering the client a bedpan, is not the priority because it does not address the underlying issue of the client feeling the need to move her bowels. It is important to determine if this urge is actually due to the baby descending rather than the need for bowel movement. Option C, notifying the physician, is not the first step because the nurse should assess the situation and provide immediate care based on their assessment. The physician can be notified after the evaluation of labor progress has been completed. Option D, encouraging the patient to push, is also not the correct first step because pushing should only be done when the client is fully dilated and ready to deliver. Encouraging pushing prematurely can lead to complications and should be avoided until the client is fully evaluated. In conclusion, evaluating the progress of labor is the most appropriate first step when a client feels the need to move her bowels late in labor. This allows the nurse to determine if the urge is related to the baby's descent and if delivery is imminent.