QUESTION: "After explaining about the second stage of labor, which of the following client statements would indicate to the nurse that the client understands the information discussed?"
CHOICES
( X ) a.) "I'm going to have a higher blood pressure."
( X ) b.) "My membranes are likely to have a foul odor."
( X ) c.) "My contractions are going to be less painful."
( O ) d.) "I should try to push with each contraction."
RATIONALE: The second stage of labor begins with complete cervical dilation and ends with delivery. During this time, the client is encouraged to push with each contraction. Throughout labor the client's blood pressure should remain within normal limits. The membranes often rupture in the second stage of labor, but they also may rupture earlier- in some instances, even before labor begins. However, the fluid should not have a foul odor, which is indicative of an infectious process. Contractions can be strong and painful in the first stage of labor as well as the second stage. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
