The physician has determined the need for forceps. The nurse should explain to the patient that the use of forceps is indicated:
1. Because her support person is exhausted.
2. Due to premature placental separation.
3. To shorten the first stage of labor.
4. To prevent fetal distress.
2
Rationale 1: Exhaustion of the support person is not an indication for use of forceps.
Rationale 2: Forceps are applied during the second stage of labor. Indications for the use of forceps include premature placental separation, nonreassuring fetal heart rate, and the need to shorten the second stage of labor in cases of maternal exhaustion or regional anesthesia.
Rationale 3: Indications for the use of forceps include the need to shorten the second (not the first) stage of labor in cases of maternal exhaustion or regional anesthesia.
Rationale 4: Indications for the use of forceps include premature placental separation and a nonreassuring fetal heart rate. Using forceps does not prevent fetal distress.
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A) "This might or might not be a problem. Watch for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring the child to the emergency room immediately so an assessment for Reye syndrome can be made." B) "This is a serious problem. Aspirin is likely to cause Reye syndrome, and the child should be admitted to the hospital for observation as a precaution." C) "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus." D) "This might or might not be a problem. Watch the child for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring the child to the emergency room to be assessed for Reye syndrome."