What is an accurate nursing assessment of the situation?

Correct Answer: B

Rationale: B: The client is exhibiting expected behavior for labor. This is the correct answer because during labor, it is common for clients to exhibit certain behaviors such as increased pain, restlessness, vocalization, and changes in vital signs. These are all normal responses to the physiological process of childbirth. As a nurse, it is important to recognize and differentiate between normal labor behaviors and signs of distress. A: The client had poor childbirth education. This answer is incorrect because the client's level of education about childbirth does not necessarily dictate their behavior during labor. Even clients who have received extensive childbirth education may still exhibit expected behaviors during labor. It is crucial for nurses to focus on assessing the client's current situation and response to labor rather than making assumptions based on their education level. C: The client is becoming hypoxic. This answer is incorrect because hypoxia (lack of oxygen) is a serious condition that requires immediate intervention. Signs of hypoxia include cyanosis, altered mental status, and difficulty breathing. While it is important for nurses to monitor for signs of hypoxia during labor, there is no indication in the question stem that the client is experiencing hypoxia at this time. D: The client needs alpha-fetoprotein levels checked. This answer is incorrect because alpha-fetoprotein levels are not relevant to assessing the client's situation during labor. Alpha-fetoprotein testing is typically done during pregnancy to screen for neural tube defects and chromosomal abnormalities in the fetus, not to assess the client's condition during labor. Nurses should focus on labor progress and the client's well-being during this time.

Correct Answer: C

Rationale: During labor, intense back pain is often associated with the baby being in the occiput posterior position. This means that the baby's head is facing the mother's abdomen, with the back of the head against the mother's spine. Choice A, Mentum anterior, refers to the baby's chin being positioned towards the mother's spine. This position is actually ideal for childbirth as it allows for easier passage through the birth canal and is not typically associated with intense back pain during contractions. Choice B, Sacrum posterior, refers to the baby's back being positioned towards the mother's spine. While this position can cause back pain during labor, it is not typically described as intense and is less common than occiput posterior. Choice D, Scapula anterior, refers to the baby's shoulder blade being positioned towards the mother's spine. This position is not typically associated with intense back pain during contractions, as the baby's head position is more critical in determining the experience of back pain during labor. In summary, the correct answer is C (Occiput posterior) because this position is most likely to cause intense back pain during contractions due to the baby's head pressing against the mother's spine. Choices A, B, and D are incorrect because they do not align with the typical presentation of intense back pain during labor associated with occiput posterior positioning.

Correct Answer: C

Rationale: C: Muscle relaxation is a key technique that should be included for a Lamaze-trained nulliparous client. This technique involves teaching the client how to relax their muscles during labor, which can help reduce pain and tension. Lamaze focuses on using breathing techniques and muscle relaxation to cope with labor pain, making it an essential component for a nulliparous client who is new to childbirth. A: Hypnotic suggestion is not typically a technique included in Lamaze training. While some individuals may find hypnosis helpful for pain management during labor, it is not a standard component of Lamaze education. Therefore, this technique would not be recommended for a Lamaze-trained nulliparous client. B: Rhythmic chanting is also not a technique commonly included in Lamaze training. While some women may find chanting or other forms of vocalization helpful during labor, it is not a primary focus of Lamaze techniques. Therefore, this would not be a necessary technique to include for a Lamaze-trained nulliparous client. D: Abdominal massage is not a standard technique taught in Lamaze training. While massage can be a helpful form of pain relief during labor, specifically focusing on the abdominal area may not be a primary focus of Lamaze education. Therefore, this technique would not be essential for a Lamaze-trained nulliparous client.

Correct Answer: B

Rationale: The correct action for the nurse to take for a client experiencing tingling fingers and lightheadedness after rapid breathing is to have the woman breathe into a bag (Choice B). This symptom presentation is indicative of hyperventilation, where the client is breathing too quickly, resulting in decreased levels of carbon dioxide in the blood. Breathing into a bag helps the client re-breathe the exhaled carbon dioxide, which can help restore the balance of gases in the blood and alleviate symptoms. Assessing the blood pressure (Choice A) may not be the most immediate action to take in this situation. While monitoring blood pressure is important in assessing overall health, it may not directly address the symptoms of tingling fingers and lightheadedness associated with hyperventilation. Turning the woman onto her side (Choice C) is not the most appropriate action for a client experiencing hyperventilation. While this action may be helpful in other situations, such as preventing aspiration in a client who is vomiting, it does not address the underlying cause of hyperventilation. Checking the fetal heart rate (Choice D) is not necessary in this situation unless the client is pregnant. In the context of hyperventilation, the priority is to address the client's symptoms and help restore normal breathing patterns. Checking the fetal heart rate would not directly address the client's symptoms of tingling fingers and lightheadedness.

Correct Answer: A

Rationale: During the second stage of labor, it is crucial for the woman to push effectively to help move the baby through the birth canal. If a client falls asleep immediately after a contraction during this stage, it is important for the nurse to awaken the woman and remind her to push. This is the correct answer because pushing during contractions helps facilitate the descent of the baby and prevents prolonged labor or potential complications. Option B: Covering the woman's perineum with a sheet is not the appropriate action in this scenario. While perineal support is important during delivery to prevent tearing, it is not the priority when the woman is not actively pushing. Option C: Assessing the woman's blood pressure and pulse may be necessary during labor, but it is not the immediate action required when the woman falls asleep after a contraction during the second stage. The priority is to ensure the progress of labor by encouraging the woman to push. Option D: Administering oxygen via a face mask is not indicated in this situation unless there are specific signs of distress or hypoxia in the mother or baby. Falling asleep after a contraction is not necessarily a sign of oxygen deprivation, so oxygen administration would not be the appropriate intervention.