SITUATION:In your area of assignment which is LABOR AND DELIVERY, you get to handle varied cases of birthing mothers. The following conditions apply.86. You are attending to Nicole, whose cervix is completely dilated and with the fetal head is at 2 (-) station. The head of Nicole's fetus has not descended in the past hour. What most appropriate initial assessment should you make?*1 pointA.Determine if Nicole's bladder is distendedB.Assess fetal status, fetal heart tones, and scalp pHC.Submit Nicole for x-rays to determine fetal sizeD.Notify the surgical team so that an operative delivery can be planned

A client who is pregnant at 39 weeks gestation spontaneously ruptured her membranes while ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action?A. Assess the color of the amniotic fluidB. Perform a vaginal examination to assess the cervix for dilationC. Inform the client she is now on strict bed rest until further noticeD. Assess the fetal heart tones

Nicole just had a vaginal delivery of her second child 2 days ago. She breastfeeds her baby without difficulty. You visited her and during your postpartum assessment you EXPECT normal findings to be as:*1 pointA.Fundic height at 1 cm above the umbilicusB.Some feeling of after painsC.Voiding frequently, 50-75 mL per episode of voidingD.Pinkish to brownish vaginal discharge

71.  Nursing care during the second stage of labor include:*1 pointA. coach breathing, encourage to bear down with each contractionB. careful evaluation of prenatal historyC. shave the perineumD. administer enema to the patient72.  The nurse is caring for a client on her 2nd postpartum day. The nurse should expect the client's lochia to be:*1 pointA. red and moderateB. brown and scantyC. continuous with red clotsD. thin and white73.  The nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client’s fundus?*1 pointA. 1 fingerbreadth above the umbilicusB. at the level of the umbilicusC. 1 fingerbreadth below the umbilicusD. below the symphysis pubis74. The nurse is helping to prepare a client for discharge following childbirth. During teaching a session, the nurse instructs the client to do Kegel exercise. What is the purpose of this exercise?*1 pointA. to tone the abdominal musclesB. to strengthen the perineal musclesC. to prevent urine retention .D. to relieve lower back pain75. Which of the following characteristics best describes that lochia is normal?*1 pointA. lochia amount increases with strenuous exerciseB. lochia is absent during the first 1-3 weeks after a cesarean birth.C. lochia contains no large clotsD. lochia is white for the first 1-3 days postpartum

The nurse is aware that a client at 40 weeks’ gestation is experiencing true labor if:*1 pointA. cervical dilatation has occurredB. the pains become more noticeableC. her membranes have rupturedD. the fetal heart rate baseline decreases

The nurse is assessing a client who is two days postpartum and is breastfeeding her infant and reports uterine contractions while breastfeeding. The nurse should take which action?A. Perform a vaginal examinationB. Prepare the client for a pelvic ultrasoundC. Reassure the client that this is a normal findingD. Instruct the client to bottle feed the infant until the sensation subsides