NursingPlex
    Sign In
    ATI Maternity Proctored Exam

    A nurse is teaching a student nurse about the anticipated care of a maternal client with ruptured membranes during the second stage of labor. Which of the following statements by the student indicates an understanding of the teaching?

    Explanation & Rationale

    A) The client will progress one station every 2 hours: This statement is inaccurate. The progress of labor in terms of fetal station does not follow a predictable or uniform rate. While some progression might occur every hour or two, it varies greatly depending on factors such as the position of the fetus, maternal anatomy, and strength of contractions. Labor can progress at different rates, and not all clients will experience consistent progression every 2 hours. B) The client should feel the urge to push at -2 station: This statement is incorrect. The urge to push generally occurs once the fetal head has descended to +1 or +2 station, which is closer to the perineum. At -2 station, the fetal head is still relatively high in the pelvis, and the client typically will not feel the urge to push until the head is lower. The urge to push is often experienced when the fetal head is well engaged in the pelvis and ready for delivery. C) The client's temperature will need to be checked every hour when the membranes have ruptured: This statement is correct. Once the membranes have ruptured, there is an increased risk of infection, as the protective barrier of the amniotic sac is no longer intact. Checking the maternal temperature every hour is an essential practice to monitor for signs of infection, such as chorioamnionitis, especially since the longer the rupture lasts, the greater the risk of infection. A rise in temperature is a key indicator of infection in the postpartum period. D) The client's cervix will need to be checked every 30 minutes: This is not correct practice. Cervical checks should be performed only when clinically indicated, not routinely every 30 minutes. Frequent cervical checks can increase the risk of infection, especially after the membranes have ruptured. The cervix should be assessed when there is a clinical reason to do so, such as checking for progress in labor or when considering interventions like an epidural or pushing.

    🔒 Submit your answer to reveal