The nurse knows that the second stage of labor, the descent phase, has begun when the:
1. amniotic membranes rupture.
2. cervix cannot be felt during a vaginal examination.
3. woman experiences a strong urge to bear down.
4. presenting part is below the ischial spines.
3
1. Incorrect. Rupture of membranes has no significance in determining the stage of labor.
2. Incorrect. The second stage of labor begins with full cervical dilation.
3. Correct. During the descent phase of the second stage of labor, the woman may expe-rience an increase in the urge to bear down.
4. Incorrect. Many women may have an urge to bear down when the presenting part is be-low the level of the ischial spines. This can occur during the first stage of labor as early as 5 cm dilation.
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Introspective or meditative techniques may be useful for clients who:
1. Are highly anxious. 2. Have multiple problems. 3. Are severely depressed, delusional, or hallucinating. 4. Are mentally and emotionally healthy.
At the completion of a family assessment the nurse provides positive feedback to the parents and adult children. What type of feedback did the nurse most likely provide to this family?
1. Father's employer cut hours and salary. 2. Mother starting a home sewing business. 3. Oldest daughter starting a new job next week. 4. Oldest son moving into an apartment within a month.
What alternative therapies have been found helpful for some patients with somatoform disorders? (Mark all that apply.)
A) Pharmacotherapy B) Massage therapy C) Herbal medicine D) Meditation E) Group therapy
The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?
A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting