Interventions: position woman on her side until s/s subside & vital signs stabilize within
normal limits.
A client is admitted to the birthing unit in active labor. Which physiologic changes should the
nurse anticipate after an amniotomy is performed?
, Maternity Exam with Complete Solutions
Progressive dilation & effacement Correct Ans-Artificial rupture of the membranes
(amniotomy) allows more effective exertion of pressure of the fetal head on the cervix,
enhancing dilation and effacement. Vaginal bleeding may increase because of the progression
of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become
greater because contractions usually increase in intensity and frequency after the membranes
are artificially ruptured.
During the second stage of labor the nurse discourages the client from holding her breath
longer than 6 seconds while pushing with each contraction. Which complication does this
prevent?
Fetal hypoxia Correct Ans-Prolonged breath holding at this stage of labor can result in
decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations
occur with rapid, uncontrolled expulsion of the fetus.
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What
stage of labor does the nurse record?
First Correct Ans-The first stage of labor is from zero cervical dilation to full cervical
dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal
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