What is a reasonable conclusion by the nurse based on Leopold's maneuvers?

Correct Answer: C

Rationale: Leopold's maneuvers are a series of four steps used to assess the position of the fetus in the uterus. Step 1: In the first step, the nurse determines which part of the fetus is located in the upper abdomen. This helps to identify the fetal presentation. Step 2: The second step involves palpating both sides of the uterus to determine which side the fetus's back is on. This helps to determine the fetal position. Step 3: In the third step, the nurse determines the location of the presenting part in the pelvis. This helps to determine the fetal station and engagement. Step 4: The final step involves palpating the lower abdomen to determine the position of the fetal back and limbs. This helps to determine the fetal lie. In this scenario, based on Leopold's maneuvers, if the nurse determines that the fetus's back is on the right side of the mother's abdomen and the small parts are felt on the left side, this indicates a longitudinal lie. A vertical lie means that the fetus's long axis is parallel to the mother's long axis. This is the correct answer. Choice A is incorrect because a transverse fetal position means that the fetus is lying horizontally across the mother's abdomen, which would not be determined by Leopold's maneuvers. Choice B is incorrect because the fetal presentation refers to the part of the fetus that is entering the maternal pelvis first. This is usually determined during the vaginal examination, not by Leopold's maneuvers. Choice D is incorrect because fetal attitude refers to the relationship of the fetal body parts to one another. It is not determined by Leopold's maneuvers, which focus on the position of the fetus in the uterus.

Correct Answer: A

Rationale: The correct answer is A. Descent is progressing well. This is because the primipara is in active labor, 7 cm dilated, and at +3 station. At this point, the fetus is descending through the birth canal, which indicates progress in labor. The +3 station means that the fetal head is 3 cm below the ischial spines in the pelvis, which is a good sign that descent is occurring as expected. Therefore, it is important for the nurse to report that descent is progressing well. Choice B, fetal head is not yet engaged, is incorrect. The fact that the fetus is at +3 station indicates that the fetal head is engaged and descending into the pelvis. This is a positive sign of progress in labor. Choice C, vaginal delivery is imminent, is incorrect. While the primipara is at 7 cm dilated and at +3 station, it is not guaranteed that delivery is imminent. Labor can still take some time to progress further before delivery occurs. Choice D, external rotation is complete, is incorrect. External rotation occurs during the second stage of labor, not during active labor. At this point, the focus is on descent and dilation, rather than rotation of the fetus.

Correct Answer: C

Rationale: During the second stage of labor, the most appropriate breathing technique is to push down with an open glottis, which is option C. This technique is also known as the "pushing" stage of labor, where the mother actively works to push the baby through the birth canal. Option A, alternately pant and blow, is not the most appropriate technique during the second stage of labor. Panting and blowing are more commonly used during the first stage of labor to help manage contractions and stay relaxed. Option B, taking rhythmic, shallow breaths, is also not the most appropriate technique during the second stage of labor. This type of breathing may not provide enough power and force to effectively push the baby out. Option D, doing slow chest breathing, is not suitable for the second stage of labor either. Slow chest breathing is usually used for relaxation and pain management, rather than actively pushing during labor. In conclusion, pushing down with an open glottis is the most appropriate breathing technique during the second stage of labor because it helps the mother effectively push the baby through the birth canal.

Correct Answer: D

Rationale: During labor, tense shoulder and face muscles can be a sign of increased anxiety or pain. Encouraging the woman to perform next-level breathing is the most appropriate first intervention in this situation. Next-level breathing involves deep, slow breaths that help the woman relax and focus during contractions. This can help alleviate some of the tension in the shoulder and face muscles. It also promotes better oxygenation, which can be beneficial for both the mother and the baby during labor. Encouraging an epidural (choice A) or intravenous analgesia (choice B) may be appropriate interventions for pain relief in labor, but they should not be the first step when dealing with tense shoulder and face muscles. These interventions are more invasive and should be considered after less invasive interventions have been tried. Assisting the woman in changing position (choice C) can also help relieve tension and discomfort during labor. However, next-level breathing is a more immediate and easily implementable intervention that can be performed at any time during labor. Changing positions may require more time and effort, so it may not be the most appropriate first step in this situation. In conclusion, urging the woman to perform next-level breathing is the best initial intervention for tense shoulder and face muscles during contractions because it is non-invasive, can be done immediately, and promotes relaxation and focus during labor.

Correct Answer: A

Rationale: After auscultating a fetal heart rate of 152 bpm in early labor, the nurse should inform the mother that the rate is normal. This is the correct answer because a normal fetal heart rate during labor typically ranges from 110-160 bpm. A rate of 152 bpm falls within this normal range, indicating that the fetus is tolerating labor well and there is no immediate cause for concern. Reassessing in 5 minutes to verify results (Choice B) is unnecessary in this situation since the heart rate is already within the normal range. There is no need to wait and reassess as it may cause unnecessary anxiety for the mother. Immediately reporting the rate to the health care practitioner (Choice C) is not necessary as well since the fetal heart rate is normal. Reporting every normal finding to the healthcare provider can result in unnecessary interventions and undue stress for the mother. Placing the client on her left side and applying oxygen (Choice D) is not indicated for a normal fetal heart rate in early labor. These interventions are typically reserved for situations where there are signs of fetal distress, such as a decrease in heart rate or variability. In this case, the fetal heart rate is normal, so there is no need for these measures. Informing the mother that the rate is normal is the most appropriate action to take in this scenario.