The nurse is providing care to the client during the second stage of labor.Which nursing action is appropriate?
A) Assessing maternal temperature every 2-4 hours after amniotic membranes have ruptured
B) Encouraging the client to void because a full bladder can interfere with fetal descent
C) Assessing fetal heart rate every 15 minutes in low risk clients
D) Administering antibiotics for a positive group beta strep

Question

Quizplus · Accepted Answer

A) The second stage of labor is reached when the cervix is completely dilated. At this time, it is appropriate for the nurse to assess fetal heart rate every 15 minutes in low risk clients and every 5 minutes in high risk clients. Assessing temperature every 2 to 4 hours after amniotic membranes have ruptured, encouraging the client to void, and administering antibiotics are all nursing actions that are appropriate during the first stage of labor.
B) The second stage of labor is reached when the cervix is completely dilated. At this time, it is appropriate for the nurse to assess fetal heart rate every 15 minutes in low risk clients and every 5 minutes in high risk clients. Assessing temperature every 2 to 4 hours after amniotic membranes have ruptured, encouraging the client to void, and administering antibiotics are all nursing actions that are appropriate during the first stage of labor.
C) The second stage of labor is reached when the cervix is completely dilated. At this time, it is appropriate for the nurse to assess fetal heart rate every 15 minutes in low risk clients and every 5 minutes in high risk clients. Assessing temperature every 2 to 4 hours after amniotic membranes have ruptured, encouraging the client to void, and administering antibiotics are all nursing actions that are appropriate during the first stage of labor.
D) The second stage of labor is reached when the cervix is completely dilated. At this time, it is appropriate for the nurse to assess fetal heart rate every 15 minutes in low risk clients and every 5 minutes in high risk clients. Assessing temperature every 2 to 4 hours after amniotic membranes have ruptured, encouraging the client to void, and administering antibiotics are all nursing actions that are appropriate during the first stage of labor.

The Nurse Is Providing Care to the Client During the Second