Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?

Correct Answer: C

Rationale: The correct answer is C because offering warm wet cloths to place on the patient's face and neck can help promote relaxation by providing a soothing sensation. This measure can help to reduce stress and tension, creating a calming environment for the laboring woman. A: Recommending frequent position changes can help with labor progress and comfort, but it may not specifically address relaxation. B: Palpating the filling bladder every 15 minutes is important for monitoring urinary output, but it is not a direct comfort measure for relaxation. D: Keeping the room lights lit may be necessary for visibility, but bright lights can be distracting and may hinder relaxation.

Correct Answer: D

Rationale: The correct answer is D because the patient is gravida 3, para 2, with a history of the shortest previous labor of 4 hours. This indicates a high likelihood of rapid labor progression, necessitating immediate hospital or birth center access to ensure timely delivery. Choice A lives 10 minutes away, which may not be enough time in case of rapid labor. Choice B, living 40 minutes away, poses a risk of delivering en route. Choice C's previous labor duration of 16 hours suggests a longer labor, making immediate hospital arrival less critical.

Correct Answer: C

Rationale: The correct answer is C: Report the fetal heart rate to the physician or nurse-midwife immediately. A fetal heart rate of 152 bpm is within the normal range for a fetus, but it is essential to communicate any findings to the healthcare provider for further assessment and monitoring. This step ensures the safety and well-being of both the mother and the fetus by allowing the healthcare provider to determine if any additional actions are necessary. Incorrect choices: A: Inform the mother that the fetal heart rate is normal - While the heart rate may be normal, it is crucial to involve the healthcare provider for proper evaluation. B: Reassess the fetal heart rate in 5 minutes because the rate is too high - 152 bpm is not considered too high, and immediate reporting to the healthcare provider is necessary. D: Suggest to the mother that she is going to have a boy because the heart rate is fast - Fetal heart rate is not a reliable indicator of the baby's gender, and this

Correct Answer: B

Rationale: The correct answer is B because the vulva bulging and encircling the fetal head is a sign that the baby is descending through the birth canal, indicating the patient is almost ready to give birth. This is known as crowning. A: Bloody mucous discharge increasing is a sign of early labor, not necessarily indicating imminent birth. C: Feeling the fetal head at 0 station means the baby is engaged in the pelvis, but it does not indicate the exact timing of birth. D: Membranes rupturing during a contraction can happen at any stage of labor and do not necessarily signify imminent birth.

Correct Answer: A

Rationale: The correct answer is A: massage the fundus. After childbirth, a soft fundus indicates uterine atony, which can lead to postpartum hemorrhage. Massaging the fundus helps stimulate contractions and reduce bleeding, promoting uterine tone. This intervention is crucial in preventing complications. Taking blood pressure (B) is important but not the priority in this situation. Increasing blood supply to the hands and feet (C) is not relevant to addressing uterine atony. Notifying the physician or nurse-midwife (D) can be done after initiating immediate intervention to manage the soft fundus.