What signs indicate progression into the second stage of labor? Select all that apply.

Correct Answer: A

Rationale: In the second stage of labor, the cervix is fully dilated at 10 centimeters and the baby is pushed through the birth canal. Option A, bulging perineum, is a sign that indicates progression into the second stage of labor. This occurs as the baby's head descends and puts pressure on the perineum, causing it to bulge outward. This is a clear indication that the second stage of labor has begun. Option B, increased bloody show, is not necessarily a sign of progression into the second stage of labor. Bloody show is a common sign of labor but it can occur in the first stage as well. It is caused by the release of the mucus plug that seals the cervix during pregnancy. Option C, spontaneous rupture of membranes, is also not a definitive sign of progression into the second stage of labor. This can happen at any point during labor and does not necessarily indicate the beginning of the second stage. Option D, inability to breathe through contractions, is not a sign of progression into the second stage of labor. While contractions can become more intense and frequent in the second stage, breathing techniques can still be used to help manage the pain and discomfort. In summary, the bulging perineum is the most reliable sign that indicates progression into the second stage of labor. Other signs mentioned in the options can occur at various points during labor and are not specific to the second stage.

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.

Correct Answer: C

Rationale: Direct sacral pressure is the most effective intervention for severe back labor because it can help alleviate the intense lower back pain experienced during labor. This technique involves applying pressure to the sacrum, the triangular bone at the base of the spine, which can help relieve the pressure on the nerves causing the pain. By providing direct sacral pressure, the mother can experience some relief and potentially progress more smoothly through labor. Assisting the mother with childbirth breathing (Choice A) is a helpful technique during labor, but it may not be the most effective intervention for severe back labor specifically. While deep breathing and relaxation techniques can help manage pain and reduce stress, they may not directly address the intense lower back pain associated with back labor. Encouraging the mother to have an epidural (Choice B) is another option for pain management during labor. However, an epidural may not specifically target the lower back pain associated with back labor. Additionally, epidurals come with potential risks and side effects that may not be necessary if direct sacral pressure can provide relief. Using a hydrotherapy tub (Choice D) can be a soothing and relaxing option for pain management during labor. However, it may not be as effective for severe back labor specifically. While warm water can help relax muscles and provide some pain relief, it may not directly target the intense lower back pain experienced during back labor. In conclusion, providing direct sacral pressure is the most effective intervention for severe back labor as it directly addresses the intense lower back pain experienced during labor. Other options such as childbirth breathing, epidurals, and hydrotherapy tubs may provide some relief but may not be as targeted or effective for severe back labor specifically.