Maternal Child Nursing Care Chapter 16 Nursing Care of the Family During Labor and Birth

4 Because monitoring is essential to assess fetal well-being, it is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low-risk pregnancy and as long as labor is progressing normally. Having the woman's sister as her coach, using Lamaze techniques to reduce pain, and using a birthing room are realistic plans for the birth.

A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan is considered unrealistic and requires further discussion with the nurse? 1 "My husband and I have agreed that my sister will be my coach because he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK." 2 "We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor." 3 "We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born." 4 "We do not want the fetal monitor used during labor because it will interfere with movement and doing effleurage."

4 Leopold maneuvers (abdominal palpation) help identify the degree of descent into the pelvis of the presenting part in a pregnant patient. Therefore the nurse should grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly in order to determine whether the fetal head is flexed or extended. Identifying the fetal part that occupies the fundus of the patient helps to identify the fetal position. The fetal head is palpated with the palmar surface of the fingertips using both hands, but not with only the right hand to determine the cephalic prominence. Palpation of the smooth convex contour of the fetal back and irregularities using the palmar surface of one hand is not used to determine the attitude of the fetal head. This maneuver helps identify the feet, hands, and elbows of the fetus.

During an assessment, the nurse is instructed to determine the position of the fetal head in a pregnant patient. What should the nurse do to determine whether the fetal head is flexed or extended? 1 Palpate the fetal head with the palmar surface of the fingertips of the right hand. 2 Identify the fetal part that occupies the fundus in the uterus of the pregnant patient. 3 Palpate the smooth convex contour of the fetal back using the palmar surface of one hand. 4 Grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly.

2 The infant should be dried to prevent cold stress due to rapid loss of heat and then covered with a warm blanket. The Apgar score is to be recorded at 1 and 5 minutes after the birth of the infant. Recording it after 30 minutes may lead to failure in assessing the fetal signs. The cord should be cut at 2.5 cm above the placement of the clamp. A newborn may be very slippery to hold, and the mother may not be able to hold the baby due to fatigue. The infant can be given to the mother only after complete drying.

The nurse is caring for a pregnant patient during labor. What should the nurse do immediately after the child's birth? 1 Ask the mother to hold the infant. 2 Dry the infant and place in warm blanket. 3 Record the Apgar scores after 30 minutes. 4 Cut the umbilical cord 3.5 cm above the clamp.

4 The hands-and-knees position is suitable for patients with back pain and for patients experiencing back labor, because it reduces stress on the back. The lateral position can be used when the patient is receiving a back rub, but this position does not offer relief from back pain. An upright position may not have a significant effect on back pain. Therefore this position is not planned for childbirth. The semirecumbent position does not support the back, so back pain may not be relieved.

The patient reports severe lower back pain during labor. Which position does the nurse plan for the patient during childbirth? 1 Lateral position 2 Upright position 3 Semirecumbent position 4 Hands-and-knees position

3 When the membranes rupture, there is a possible risk of infection, as the microorganisms can ascend form the vagina to the uterus. Ruptured membranes can be assessed by monitoring the body temperature and vaginal discharge every 2 hours. The assessment is not used for knowing the onset of labor because it does not indicate the progress of labor. The fetal status is not known by the assessment of the temperature and vaginal show; it may be known by another procedure called Leopold maneuvers. This measure is not done to prevent fetal hypertension, because the maternal body temperature and vaginal discharge does not indicate fetal blood pressure.

The primary health care provider (PHP) advised the nurse to assess the maternal temperature and vaginal discharge of a pregnant patient every 2 hours. What is the reason behind this advice? 1 To evaluate fetal status 2 To know the onset of labor 3 To assess for potential risk for infection 4 To prevent fetal hypertension

4 Sudden appearances of sweat on the upper lip, shaking of the extremities, and vomiting indicate the onset of the second stage of labor. Irregular and mild to moderate uterine contractions (UCs) indicate the onset of the latent phase of the first stage labor. Postural hypotension is characterized by a sudden fall in the blood pressure while changing the position. Respiratory depression is characterized by a decreased rate of respiration.

The student nurse finds that the patient who is in labor has sweat on the upper lip, is shivering in the extremities, and is vomiting. What would the student nurse interpret from these observations? The patient has symptoms of: 1 Postural hypotension. 2 Respiratory depression. 3 Onset of the first stage of labor. 4 Onset of the second stage of labor.

3 Regular and strong UCs may occur in the transition phase of labor. Absence of uterine contractions means that the labor has not started. Mild UCs can be observed during early labor. Mild to moderate UCs can be observed during the latent and active phases of labor.

he nurse is examining a newly admitted patient who is 39 weeks pregnant and notes that the patient is in the transition phase of labor. Which symptoms does the nurse note to reach this conclusion? 1 No evidence of uterine contractions (UCs) 2 Mild uterine contractions (UCs) 3 Strong uterine contractions (UCs) 4 Moderate uterine contractions (UCs)

4 A first-degree laceration extends through the skin and structures superficial to muscles. A second-degree laceration extends through muscles of the perineal body. A third-degree laceration continues through the anal sphincter muscle. A fourth-degree laceration involves the anterior rectal wall.

A patient sustained a first-degree laceration during childbirth. What physical finding should the nurse infer from this? The laceration: 1 Also involves the anterior rectal wall. 2 Continues through the anal sphincter muscle. 3 Extends through muscles of the perineal body. 4 Extends through the skin and structures superficial to muscles

2 The nurse should place the patient in a position that helps the rotation of the fetal occiput from a posterior to an anterior position. Therefore the nurse should encourage the patient to sit in hands-and-knees position, as it increases the pelvic diameter, allowing the head to rotate toward anterior position. The patient should not lie in supine position, as it may cause postural hypotension. Placing a pillow under the patient's hip when lying in supine position helps prevent supine hypotensive syndrome, but does not help in delivering the baby. The nurse should not ask the patient to lie in lateral position on the opposite side of the fetal spine, as it increases counter pressure on the back. Instead, lying in lateral position on the same side of the fetal spine will help the fetus rotate toward the posterior, as the gravity pulls the fetal back forward.

After performing Leopold maneuvers, the nurse finds that the fetus of a pregnant patient is in occiput posterior position. Which suitable action should the nurse employ while caring for the patient? 1 Help the patient to lie in supine position on the bed. 2 Encourage the patient to sit in hands-and-knees position. 3 Place a pillow under the patient's hip when lying in supine position. 4 Ask the patient to lie in lateral position on the opposite side of the fetal spine.

1 I.V. fluids are administered to increase the amount of fluids and restore the electrolyte balance. As the patient is dehydrated, the PHP advises the nurse to administer I.V. fluids. Administration of I.V. fluids as a medical treatment for the prevention of preterm labor is not indicated unless medical management involves use of therapeutic protocols such as magnesium sulfate. As the patient is at term, preterm labor would not be a factor. Administering fluids may increase the venous pressure, thereby enhancing the blood pressure. Therefore I.V. fluids must not be administered if the patient has hypertension. Other prospective medical management should be initiated if maternal hypertension is noted. I.V. fluids should not be administered to hyperglycemic patients, but rather other prospective medical management should be initiated if maternal hyperglycemia is noted and deemed to be significant.

After reviewing the laboratory reports of a pregnant patient at term, the primary health care provider (PHP) advised the nurse to administer intravenous (I.V.) fluids to the patient. What is the reason for giving such advice? 1 Dehydration 2 Hypertension 3 Maternal hyperglycemic 4 Preterm labor

1, 3, 5 Any comfort measures useful for the patient should be demonstrated to the patient's partner. The patient's partner may be reminded to take food. The nurse can also offer snacks and fluids to the partner. The nurse can offer to relieve him of the duty of supporting and encouraging the patient in order to get proper rest. The decision regarding the involvement of the partner in the process of labor should be left to the couple. The nurse should respect their decision. The nurse should tell the partner about the changes that may take place in the patient's behavior during labor and childbirth.

A patient has been admitted to the labor room. What are the measures to be taken by the nurse to support the partner of the patient? Select all that apply. 1 Offer snacks and fluids to the partner as required. 2 Do not discuss the psychological change in the patient. 3 Demonstrate the performance of the comfort measures. 4 Guide the partner to make decisions about his involvement. 5 Relieve the person occasionally from the job of supporting the patient.

2 The patient is experiencing uterine contractions that are 3 to 5 minutes apart and last for about 60 seconds (1 minute). The patient also exhibits flushed cheeks. These findings indicate that the patient is in the active phase of the first stage of labor. The nursing assessment in the active stage of labor is to check the patient's appearance and mood every 15 minutes, or 4 times in an hour. The patient's mood and energy levels fluctuate, and therefore the nurse should constantly assess them to ensure effective patient care. The patient's blood pressure should be assessed every 30 minutes. The nurse should assess the patient's body temperature every 4 hours until membrane rupture and thereafter every 2 hours. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A patient in labor exhibits flushed cheeks. The nurse records the uterine contractions in the patient as being 3 to 5 minutes apart and lasting for about 1 minute. What nursing intervention is most effective to assess the patient's status during this phase of labor? 1 Check blood pressure every 2 hours. 2 Note patient's appearance and mood every 15 minutes. 3 Assess the patient's temperature every 2 hours until membranes rupture.

2 Discussing the woman's fears allows her to share her concerns with the nurse and is a therapeutic communication tool. Telling the woman not to worry negates her fears and is not therapeutic. Telling the woman that labor is not scary negates her fears and offers a false sense of security. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: 1 "Don't worry about it. You'll do fine." 2 "It's normal to be anxious about labor. Let's discuss what makes you afraid." 3 "Labor is scary to think about, but the actual experience isn't." 4 "You may have an epidural. You won't feel anything."

1, 2, 3 Labor care begins with the onset of progressive, regular contractions. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when the blood-tinged mucoid vaginal discharge appears. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when amniotic fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when progressive, regular contractions begin, the blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Pain is subjective. The onset of progressive, regular contractions signals the beginning of labor, not the intensity of the pain.

For the labor nurse, care of the expectant mother begins with which situations? Select all that apply. 1 The onset of progressive, regular contractions 2 The bloody, or pink, show 3 The spontaneous rupture of membranes 4 Formulation of the woman's plan of care for labor 5 Moderately painful contractions

4 The nurse suspects that the patient may have slow progress in labor after knowing that the patient is worried and stressed, because she had complications in the previous labor. Stress may reduce the progress in the labor by decreasing the levels of catecholamines. This, in turn, reduces the UCs. Family history of diabetes does not affect the labor progression or UCs. Folic acid supplements are necessary for fetal growth and are given early in pregnancy to prevent neural tube defects. They do not affect the birth process. Taking a diet with a high amount of protein may not affect the onset of labor. Moreover, it helps in the fetal growth and development.

The nurse assesses a pregnant patient and finds that the patient has reduced strength of uterine contractions (UCs). Upon further assessment, the nurse suspects that the patient may have slow progress in labor. Which statement made by the patient indicates the reason for slow progress in labor? 1 "I have a family history of diabetes and hypertension." 2 "I stopped taking folic acid supplements a week ago." 3 "I have been on a diet with high amounts of protein for 15 days." 4 "I am worried a lot this time; I had a lot of problems in my last labor."

1, 3, 5 After an assessment, the nurse reports to the PHP that a pregnant patient is in the second stage of labor because the patient has a cervical dilation of 10 cm (fully dilated). The patient has a premature urge to bear down and an urge to defecate. The patient may have flushed cheeks in the active phase of first stage of labor, but it is not a sign of second stage of labor. Brownish discharge of mucus is a sign of latent phase of first stage of labor, but does not appear in the second stage of labor.

The nurse assesses a pregnant patient and reports to the primary health care provider (PHP) that the patient is in the second stage of labor. Which of the patient's signs enabled the nurse to give such a report to the PHP? Select all that apply. 1 Urge to defecate 2 Cheeks appear to be flushing 3 Cervical dilation of 10 cm 4 Brownish discharge of mucus from the vagina 5 Premature urge to bear down

1, 3, 4 Impaired urinary elimination occurs as a result of sensory impairment caused by the labor process. Therefore the nurse has to perform interventions that help in emptying the patient's bladder every 2 hours. The nurse should encourage the patient to void every 2 hours to avoid bladder distention. The nurse can use running water to stimulate voiding by asking the patient to keep her hands in the running water. The nurse should palpate the patient's bladder on a frequent basis to detect the inability to void. The nurse should not catheterize the patient immediately for voiding, because it may result in trauma to the bladder. Effleurage helps in reducing pain but does not help stimulate voiding in the patient.

The nurse finds that the pregnant patient has impaired urinary elimination. Which interventions should be performed by the nurse to relieve the patient's problem? Select all that apply. 1 Encourage the patient to urinate every 2 hours. 2 Catheterize the patient immediately for voiding. 3 Palpate patient's bladder superior to symphysis. 4 Ask the patient to place the hand in running water. 5 Provide effleurage massage to the patient frequently.

2 The patient has flushed cheeks, UCs of 65 seconds with a frequency of 4 minutes, and pink to bloody mucus. These symptoms are observed during the active phase of labor. The symptoms of the patient do not correlate with the latent, transition, or active pushing phases (second stage) of labor. In the latent phase of labor, the UCs are 30 to 45 seconds with a frequency of 5 to 30 minutes, and the mucus is pale pink. In the transition phase, the UCs are 45 to 90 seconds with a frequency of 2 to 3 minutes, and the mucus appears bloody. In the active pushing phase of the second stage of labor, the UCs are 90 seconds with a frequency of 2 to 2.5 minutes.

The nurse is assessing a pregnant patient in the last week of gestation. The nurse observes that the patient has flushed cheeks, uterine contractions (UCs) of 65 seconds with a frequency of 4 minutes, and pink to bloody mucus. What stage of labor should the nurse infer that the patient is in based on these observations? 1 Latent phase 2 Active phase 3 Transition phase 4 Active pushing phase

2 Some patients often wish to breastfeed after the ejection of the milk. The patient cannot be given instruction to breastfeed 1 hour after birth. The patient may require rest, but breastfeeding should be encouraged only after the milk ejection. Some patients prefer to breastfeed during the infant's reactive state, but patients of a Hispanic background may not choose to do this, as it may not fall within their cultural belief system. The nurse should always respect the cultural beliefs of the patient.

The nurse is caring for a Hispanic patient who has given birth to a baby. When does the nurse expect the patient to start breastfeeding? 1 First hour after birth 2 When the milk comes 3 When the infant cries 4 After the patient has rested

2, 3, 5 The parents may be worried about the newborn's dusky appearance. Therefore the nurse should properly explain to the parents that the baby may initially appear dusky. The color may become normal once the circulation is established. Siblings may be encouraged to hold the newborn to promote bonding between them. The infant's head is molded due to the narrowness of the birth canal and the pelvic structures. This is to be explained to the parents. Southeast Asian patients consider the head to be the sacred part of the human body and should not be touched. Hence, the nurse should avoid placing hand on the infant's head. The Southeast Asian population considers any praise of the infant as harmful, as they believe the jealous spirits will take away the baby.

The nurse is caring for a Southeast Asian patient who gave birth to a child. What interventions can the nurse perform to promote bonding between the newborn and the family? Select all that apply. 1 Placing the hand on the infant's head 2 Encouraging the sibling to hold the baby 3 Explaining the molding of the infant's head 4 Praising the infant's appearance and health 5 Explaining the dusky appearance of the infant

1 It is important that the nurse explain the procedure to the patient. Because the patient does not speak English, it is advisable to call an interpreter. This helps the patient understand the test procedures without any confusion. Nonverbal communication is not useful in this case, because it may cause the patient to become confused. Explaining the medical examination procedure may include complex terms and words. Limiting those words may not help clarify to the patient who does not speak English. Finally, the patient may not feel comfortable in the presence of additional hospital staff.

The nurse is caring for a non-English-speaking pregnant patient. What nursing interventions would help explain the procedure of vaginal examination to the patient? 1 Call a service for an interpreter. 2 Try to communicate nonverbally. 3 Limit the use of medical terminologies. 4 Ask for the assistance of the hospital staff

1 The patient's perineum should be cleaned frequently to prevent the risk for infection. This helps maintain proper hygiene and provides comfort to the patient. The nurse can clean the patient's teeth with an ice-cold wet washcloth, which helps prevent a feeling of thirst and dryness of the mouth. Using a warm cloth may not be helpful. The patient is offered a cool cloth for wiping her face, which helps prevent diaphoresis. Warm water should be poured on the patient's back to provide relaxation and accelerate labor. Using a warm washcloth for a face wash and placing cool water on the patient's back will not help in providing comfort.

The nurse is caring for a pregnant patient. What interventions should the nurse follow to ensure proper hygiene in the patient? 1 Clean the perineum of the patient frequently. 2 Clean the patient's teeth with a warm wet cloth. 3 Offer a warm washcloth to the patient for a face wash. 4 Allow cool water to flow on the patient's back for 5 minutes.

2, 1, 4, 5, 3 A nitrazine dye test is performed to learn the status of the amniotic membrane in the pregnant patient. Informing the patient and her partner about the testing procedure makes the patient feel comfortable. The cotton-tipped applicator specified for this procedure is soaked in nitrazine dye. Then, the applicator is inserted into the vagina to get the fluid on the applicator. Perineal care is then performed to ensure that there is no risk of infections. Finally, the test result is seen and documented appropriately.

The nurse is preparing to perform a nitrazine pH test on a pregnant patient. Arrange the steps that the student nurse would follow while conducting the test. 1. Soak the cotton-tipped applicator in the nitrazine dye. 2. Inform the patient and the partner about the procedure. 3. Document the test reports of the patient in the patient record. 4. Insert the cotton-tipped applicator deep into the vagina. 5. Perform perennial care in the patient as required.

2 The blood glucose level of 180 mg/dL indicates that the patient has high blood glucose levels. Therefore the patient has to be administered an electrolyte solution without glucose to prevent the risk of fetal hyperglycemia and hyperinsulinism. Hence, the nurse would expect the PHP to prescribe Ringer's lactate solution to the patient, as it does not increase blood sugar levels. Lidocaine (Nervocaine) is an anesthetic preparation, which may be given during emergency. Hydromorphone (Dilaudid) is an opioid preparation and is not used in treating blood glucose levels in the body. IV solution containing a small amount of dextrose is administered to increase the fatty acid metabolism when the patient has ketosis. It is not useful to treat hyperglycemia.

The nurse observes that a pregnant patient has a blood glucose level of 180 mg/dL in early labor. Which medication order does the nurse expect to receive from the primary health care provider (PHP)? 1 Lidocaine (Nervocaine) to the patient 2 Ringer's lactate solution to the patient 3 Hydromorphone (Dilaudid) to the patient 4 Intravenous (IV) solution containing a small amount of dextrose

4 Leopold maneuvers (abdominal palpation) help identify the degree of descent into the pelvis of the presenting part in a pregnant patient. The head feels round, firm, freely movable, and palpable by ballottement when the fetus has a cephalic or breech presentation. Based on the descent of the presenting part, it may be difficult to infer the fetal position, as the presenting part can be head or buttock. The cephalic prominence on the same side as the back shows that the fetal head is extended and the face is the presenting part. This maneuver is not related to identification of fetal position. If the head is presenting to the true pelvis and is not engaged, then it determines the attitude of fetal head whether flexed or extended. It does not indicate the fetal position.

The nurse palpates the abdomen of a pregnant patient and reports that the fetus lies in longitudinal position with cephalic presentation. Which observation enabled the nurse to report about the fetal position? 1 The presenting part has deeply descended in the pelvis. 2 The cephalic prominence is on the same side as the back. 3 The head is presenting to the true pelvis and is not engaged. 4 The head feels round, firm, freely movable, and palpable by ballottement

2 The patient may have severe fatigue after labor due to depletion of energy. In order to restore the energy levels, the nurse gives a specific time for the patient to rest and sleep by restricting the visitors. Severe pain, inefficiency in the birth process, and a problem of irregular urination are not the reason for the nurse to limit visitors. The nurse would administer analgesics or anesthesia on an order if the patient experienced acute pain. The nurse would provide comfort measures if the patient was ineffective in the birth process. The nurse would palpate the patient's bladder if irregular urination were a concern.

The nurse restricts the visitors of a pregnant patient and gives a specific time for the patient to rest and sleep after the labor. What maternal patient experience could be the probable reason for this nursing action? 1 Severe pain during labor 2 Severe fatigue during labor 3 Ineffective birth process 4 Problem of irregular urination

1, 3, 4 Vaginal examinations should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After rupture of membranes (ROM), a vaginal examination should be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. An accelerated FHR is a positive sign; variable decelerations, however, merit a vaginal examination. Examinations are never done by the nurse if vaginal bleeding is present because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

Under which circumstances should a vaginal examination be performed by the nurse? Select all that apply. 1 An admission to the hospital at the start of labor 2 When accelerations of the fetal heart rate (FHR) are noted 3 On maternal perception of perineal pressure or the urge to bear down 4 When membranes rupture 5 When bright, red bleeding is observed

2, 3, 5 A nulliparous patient has rigid perineal tissue making it susceptible to injury. Fetal breech presentation exerts undue pressure on the tissues, increasing the risk of injuries. Forceps delivery also increases the risk of injury due to undue stretch of the perineum. Multiparous patients have stretchable perineal tissues, which are less likely to get injured during childbirth. Fetal vertex presentation causes the least amount of tissue damage.

Which patients are more susceptible to soft-tissue damage with vaginal deliveries? Select all that apply. 1 Multiparous patients 2 Nulliparous patients 3 Patients needing forceps delivery 4 Patients with fetal vertex presentation 5 Patients with fetal breech presentatio

2 In many instances, a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. A urine analysis should be performed on admission to labor and delivery. This test is used to identify the presence of glucose and protein. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook. Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.

Which test is performed to determine if membranes are ruptured? 1 Urine analysis 2 Fern test 3 Leopold maneuvers 4 Artificial rupture of membranes (AROM

3 A multiparous patient feels an urge to defecate in the second stage of labor due to rectal pressure by the deeply descending presenting part in the pelvis. Rectal pressure may occur even in the absence of stool in the anorectal area. This often means that the patient is about to give birth to the child. Therefore the nurse has to perform vaginal examination of the patient to assess cervical dilation and station. The patient does not really defecate, so providing a bedpan is not necessary. Placing an enema in the rectum of the patient is not a suitable intervention, as it is done to increase peristalsis. Running water is used to stimulate voiding for the patient if there is a risk of urinary elimination. However, it is unrelated to the patient's urge of defecation.

While caring for a multiparous patient in the second stage of labor, the patient reports the urge to defecate. What is the best nursing intervention? 1 Provide a bedpan to the patient to defecate. 2 Place an enema in the rectum of the patient. 3 Assess cervical dilation and station of the patient. 4 Use running water to stimulate defection for the patient.