Labor and Birth NCLEX Questions |Question with 100% correct Answer | Verified

se is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. The contractions are regular 2. The membranes have ruptured 3. The cervix is dilated completely 4. The client begins to expel clear vaginal fluid 5. The Ferguson reflex is initiated from perineal pressure - 3. The cervix is dilated completely 5. The Ferguson reflex is initiated from perineal pressure The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1. The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask 2. Place the mother in a supine position 3. Increase the rate of the oxytocin intravenous infusion 4. Document the findings and continue to monitor the fetal patterns - 1. Administer oxygen via face mask Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from