What should the nurse do after auscultating a fetal heart rate of 152 bpm in early 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.

Correct Answer: A

Rationale: A doula's role during labor is to provide emotional, physical, and informational support to the mother. Giving the mother a back rub is a key action for a doula during labor because it helps to relieve tension, promote relaxation, and provide comfort to the mother. This physical support can help the mother cope with the intensity of labor and manage pain more effectively. Assessing the fetal heart rate, checking the blood pressure, and regulating the intravenous are tasks typically performed by medical professionals such as doctors, nurses, or midwives. These tasks require specialized training and expertise to ensure the safety and well-being of both the mother and baby during labor. It is not within the scope of practice for a doula to perform these medical tasks. Therefore, giving the mother a back rub is the most appropriate action for a doula during labor as it aligns with their role of providing comfort and support to the mother. It is important for doulas to understand their role and limitations in order to provide the best possible care for the mother during labor.

Correct Answer: D

Rationale: The correct response for the nurse to make first to a client reporting bleeding at term is option D: "How much blood is there?" This is the most appropriate response because it helps the nurse assess the severity of the situation and determine the next steps in providing care for the client. Option A: "Does it burn when you void?" is incorrect because it is not relevant to the client's presenting concern of bleeding at term. This question pertains to urinary symptoms, which are not the immediate concern in this situation. Option B: "You sound frightened." is also incorrect because it focuses on the client's emotional state rather than addressing the physical symptoms of bleeding at term. While it is important to acknowledge and address the client's emotions, assessing the severity of the bleeding should take precedence. Option C: "That is just the mucus plug." is incorrect because it assumes that the bleeding is related to the mucus plug being expelled, which may not be the case. It is crucial for the nurse to gather more information about the amount and nature of the bleeding before making any assumptions about its cause. In summary, option D is the correct response because it allows the nurse to gather important information about the client's condition and determine the appropriate course of action. The other options are incorrect as they do not address the immediate concern of bleeding at term.

Correct Answer: A

Rationale: The correct order of cardinal moves of labor is internal rotation, extension, external rotation (Answer A). Firstly, internal rotation occurs when the baby's head rotates so that the widest part of the head aligns with the widest part of the pelvis. This movement helps the baby navigate through the birth canal more easily. Next, extension takes place as the baby's head extends as it passes under the mother's pubic bone. This movement allows the baby's head to move through the pelvis and be born. Finally, external rotation occurs as the baby's head rotates back to its original position, allowing the shoulders to be born. This movement facilitates the safe delivery of the baby. Now, let's discuss why the other options are incorrect: Option B (External rotation, descent, extension) is incorrect because descent typically occurs before external rotation. Descent refers to the baby's movement down the birth canal, which usually happens before external rotation. Option C (Extension, flexion, internal rotation) is incorrect because flexion typically occurs before extension. Flexion is when the baby's head is tucked into its chest, allowing it to pass through the birth canal more easily. Extension follows flexion. Option D (External rotation, internal rotation, expulsion) is incorrect because internal rotation generally occurs before external rotation. Internal rotation is necessary for the baby's head to align with the pelvis before external rotation occurs, leading to expulsion (birth). In conclusion, the correct order of cardinal moves of labor is internal rotation, extension, external rotation, making Answer A the correct choice.

Correct Answer: D

Rationale: Dysuria is a common discomfort of pregnancy that the nurse should include in the teaching for a client who is at 6 weeks of gestation. Dysuria refers to pain or discomfort during urination, which can be caused by hormonal changes or urinary tract infections common in pregnancy. It is important for the client to be aware of this discomfort so they can seek appropriate medical attention if needed to prevent complications. Breast tenderness is also a common discomfort of pregnancy that the nurse should include in the teaching. Hormonal changes can cause the breasts to become tender, swollen, or sensitive, which is a normal symptom of pregnancy. It is important for the client to know that this discomfort is common and typically resolves on its own. Urinary frequency is another common discomfort of pregnancy that the nurse should discuss with the client. Hormonal changes and the growing uterus can put pressure on the bladder, leading to increased urination frequency. It is important for the client to stay hydrated but also be aware of the need to empty their bladder frequently to avoid urinary tract infections. Epistaxis, or nosebleeds, is not a common discomfort of pregnancy that the nurse should include in the teaching. While hormonal changes can cause increased blood flow to the mucous membranes, leading to nasal congestion, nosebleeds are not typically listed as a common discomfort of pregnancy. The nurse should focus on more common discomforts that the client is likely to experience. In conclusion, dysuria, breast tenderness, and urinary frequency are common discomforts of pregnancy that the nurse should include in the teaching for a client who is at 6 weeks of gestation. Epistaxis is not a common discomfort of pregnancy and should not be included in the teaching.