What is the most therapeutic breathing technique for the latent phase of labor?

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: A

Rationale: A: The relationship between decelerations and contractions is the correct answer because fetal heart decelerations are often associated with contractions during labor. It is essential for the nurse to assess how the decelerations correspond to the timing and intensity of contractions to determine if they are indicative of fetal distress or if they are benign. Understanding this relationship helps the nurse make informed decisions about the course of action to take during labor and delivery. B: The maternal blood pressure is incorrect because while monitoring the maternal blood pressure is important for overall maternal health during labor, it is not directly related to fetal heart decelerations. Fetal heart decelerations are primarily related to the fetal well-being and response to labor, rather than maternal blood pressure. C: The gestational age of the fetus is incorrect because while knowing the gestational age is important for overall prenatal care, it does not directly impact fetal heart decelerations. The assessment of fetal heart decelerations is more focused on the fetal response to labor and any signs of distress rather than the gestational age of the fetus. D: The placement of the fetal heart electrode is incorrect because while ensuring proper placement of monitoring devices is crucial for accurate assessment of fetal well-being, it is not the primary factor to consider when noting fetal heart decelerations. The focus should be on understanding the relationship between decelerations and contractions to assess the fetal response to labor accurately.

Correct Answer: A

Rationale: During the next contraction for a woman at 10 cm dilation, 100% effacement, and +3 station, the nurse should encourage the woman to push. This is the correct answer because at this stage of labor, the woman is fully dilated, effaced, and the baby is at a station that indicates it is ready to be born. Encouraging the woman to push will help to facilitate the descent and delivery of the baby. Option B, providing firm fundal pressure, is incorrect because fundal pressure should only be used in specific situations and can be harmful if not done correctly. In this case, the woman is already fully dilated and effaced, so fundal pressure is not necessary. Option C, moving the client into a squat, is also incorrect. While squatting can sometimes help with labor progress, it is not typically recommended at this stage of labor when the woman is fully dilated and ready to push. Option D, assessing for signs of rectal pressure, is not necessary at this stage of labor. The woman is already fully dilated and effaced, so the focus should be on pushing to deliver the baby rather than assessing for further signs of progress. In conclusion, encouraging the woman to push during the next contraction is the most appropriate action to take at this stage of labor for a woman who is fully dilated, effaced, and at +3 station.

Correct Answer: D

Rationale: Option D is the correct answer because it indicates that the woman is likely in active labor and should proceed to the hospital. Contractions that are about a minute long and are so intense that the woman is unable to talk through them are typically a sign that labor is progressing. This is because these strong, regular contractions are a key indication that the cervix is dilating and labor is advancing. Option A is incorrect because contractions that are 5 to 20 minutes apart are considered to be in the early stages of labor, known as the latent phase. While these contractions may be uncomfortable, they are not typically strong enough or close enough together to indicate active labor. Option B is also incorrect because a pink discharge on the toilet tissue could be a sign of bloody show, which can occur as the cervix begins to dilate. However, this alone is not a definitive indicator of active labor and should be considered along with other signs and symptoms. Option C is incorrect because experiencing cramping for a few hours could be a sign of early labor or false labor (Braxton Hicks contractions). However, without more specific information about the intensity and regularity of the contractions, it is difficult to determine if this is a sign of active labor. In summary, option D is the correct answer because it describes strong, regular contractions that are a minute long and prevent the woman from talking through them, indicating that she is likely in active labor and should proceed to the hospital.

Correct Answer: D

Rationale: The correct answer is D: Scapula. When determining the presenting part of the fetus, the nurse must consider the lie of the baby in the uterus. In a vertical lie, the fetus is positioned vertically in the uterus, which can raise questions about the nurse's judgment due to the unusual positioning. The scapula, located on the back of the baby, is not a typical presenting part and would prompt the nurse to reevaluate their assessment. Choice A, the sacrum, is a common presenting part in a vertex presentation where the baby's head is down. Choice B, the occiput, is also a common presenting part in a vertex presentation where the baby's head is down and is the ideal position for vaginal delivery. Choice C, the menton, is the chin and is typically associated with the face presentation, which can occur in a transverse lie but not necessarily a vertical lie. In conclusion, the scapula is the correct answer as it is an unusual presenting part that would question the nurse's judgment of a vertical lie. The other choices are more common presenting parts in different fetal positions and would not typically raise concerns about the nurse's assessment.