Which of the following behaviors would be applicable to a nursing diagnosis of "risk for injury" in a patient who is in labor?

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: 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.

Correct Answer: D

Rationale: Rationale: 1. Past 42 weeks of gestation increases the risk of stillbirth. 2. Oxytocin can help initiate labor to reduce the risk. 3. Induction at this stage is considered safe and beneficial. 4. Other choices are not direct indications for oxytocin induction and may have different management strategies. Summary: - A: Multiple fetuses and polyhydramnios may require different approaches. - B: History of long labors may not necessarily indicate the need for oxytocin induction.

Correct Answer: A

Rationale: The correct answer is A because a patient in transition with contractions every 2 minutes lasting 90 seconds each is experiencing very intense and frequent contractions, indicating high uterine activity. Discontinuing oxytocin infusion is crucial in this scenario to prevent hyperstimulation, which can lead to fetal distress or uterine rupture. Choice B is incorrect because the patient is in early labor and the contractions are less frequent and less intense compared to the correct answer. Choice C is incorrect as the patient in active labor with contractions every 3 minutes lasting 60 seconds each is not as intense as the patient in transition in the correct answer. Choice D is incorrect because although the contractions are frequent and lasting longer, the intensity described in choice A is more concerning and requires immediate discontinuation of oxytocin infusion.

Correct Answer: C

Rationale: The correct answer is C: Persistent fetal bradycardia below 100 bpm. This is crucial because it indicates fetal distress and requires immediate intervention to prevent potential harm to the baby. Bradycardia below 100 bpm may indicate inadequate oxygen supply to the fetus, necessitating urgent action. Maternal vital signs in choices A and B are within normal ranges. Choice D, decreased intensity of uterine contractions, while important, is not as critical as fetal bradycardia in this scenario.