Which patient at term should proceed to the hospital or birth center the immediately after labor begins?

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: 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.

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.