Which nursing assessment indicates that a patient who is in the second stage of labor is almost ready to give birth?

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: C

Rationale: The correct answer is C: Document this evidence of normal early maternal-infant attachment behavior. This is the correct action because the mother's behavior of touching her infant with her fingertips and talking to him softly in high-pitched tones is indicative of normal maternal-infant attachment. This behavior shows that the mother is engaging with her infant in a positive and nurturing way, which is crucial for bonding and attachment. It is important for the nurse to document this behavior as it reflects a healthy interaction between the mother and her newborn. Other choices are incorrect: A: Request a social service consult for psychosocial support - This choice is not necessary as the mother's behavior indicates normal attachment and does not suggest a need for psychosocial support at this time. B: Observe for other signs that the mother may not be accepting of the infant - This choice is unnecessary as the mother's current behavior demonstrates acceptance and attachment towards her infant. D: Determine whether the mother is too fatigued to interact normally

Correct Answer: A

Rationale: The correct answer is A: Length of second-stage labor is 2 hours. This is applicable to the nursing diagnosis of "risk for injury" in a patient in labor because a prolonged second-stage labor can increase the risk of injury to both the mother and the baby. A prolonged second stage can lead to issues such as fetal distress, maternal exhaustion, and increased risk of instrumental delivery or cesarean section. Explanation for why the other choices are incorrect: B: Patient has received an epidural for pain control during the labor process - This choice does not directly address the risk for injury in labor. C: Patient is using breathing techniques during contractions to maximize pain relief - While breathing techniques can help with pain relief, it does not specifically address the risk for injury. D: Patient is receiving parenteral fluids during the course of labor to maintain hydration - While hydration is important during labor, it does not directly address the risk for injury.

Correct Answer: C

Rationale: The correct answer is C. Including test results ensuring that the fluid is not urine in the patient's record is crucial after a spontaneous rupture of membranes to confirm the presence of amniotic fluid, indicating the onset of labor. This information helps in assessing the progress of labor and ensuring the safety of both the mother and the fetus. A: Fetal heart rate is important but not directly related to the spontaneous rupture of membranes. It should be monitored separately. B: Pain level is subjective and can vary among individuals, not directly related to the rupture of membranes. D: The patient's understanding of the event is important for communication but does not provide essential clinical information related to the rupture of membranes.

Correct Answer: A

Rationale: After the baby's head is born, the immediate next step is the expulsion of the baby's body. This is because the expulsion maneuver refers to the delivery of the rest of the baby's body following the birth of the head. Restitution, internal rotation, and external rotation occur before the birth of the baby's head and are part of the cardinal movements of labor and birth. Restitution involves the realignment of the baby's head with their body after the head is born. Internal rotation refers to the baby's head turning to navigate through the birth canal. External rotation involves the baby's head turning back to its original position after delivery. So, the correct answer is A (Expulsion), as it directly follows the birth of the baby's head.