A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make to the client?

You should try to pant as the delivery proceeds

You should try to perform slow-paced breathing

You should take a deep cleansing breath and breathe naturally

You should go ahead and push to assist the delivery

Answer and Explanation

The Correct Answer is A

a. Panting helps to control the urge to push and can slow down the delivery, which is important to prevent rapid delivery that could cause injury to both the mother and the baby. It allows the nurse or healthcare provider to better manage the delivery process.

b. Slow-paced breathing is often used during early labor to help manage pain and anxiety. However, when the baby’s head is crowning, panting is more effective in controlling the urge to push and slowing down the delivery process.

c. While deep cleansing breaths can be helpful during contractions to manage pain and focus, they are not as effective as panting in controlling the urge to push during the crowning phase.

d. While it might seem natural to encourage pushing when the baby’s head is crowning, it’s important to control the delivery to prevent rapid birth, which can cause injury to both the mother and the baby. Encouraging the mother to pant helps slow down the process, allowing for a more controlled and safer delivery.

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Correct Answer is A

Explanation

The correct answer is A. Decreased platelet count.

A. Decreased platelet count: ITP is characterized by a decreased platelet count. It is an autoimmune disorder where the immune system attacks and destroys platelets, leading to a reduction in the number of circulating platelets.

B. Increased erythrocyte sedimentation rate (ESR): ITP is not typically associated with an increased ESR. ESR is a marker of inflammation, and ITP is primarily a disorder of platelet destruction rather than inflammation.

C. Decreased megakaryocytes: ITP is often associated with normal or increased numbers of megakaryocytes in the bone marrow. Megakaryocytes are the precursor cells for platelets, and their increased presence indicates that the bone marrow is trying to produce more platelets to compensate for the destruction occurring in the bloodstream.

D. Increased WBC: ITP primarily affects platelet counts and does not necessarily lead to an increased white blood cell (WBC) count. The primary concern in ITP is the risk of bleeding due to low platelet levels.

A. Provide clean, dry underpads. B. Monitor the client's temperature. C. Assess the fetal heart rate. D. Assess the odor of the amnio?s fluid

Correct Answer is C

Explanation

The correct answer is C. Assess the fetal heart rate.

A. Providing clean, dry underpads is important for maintaining cleanliness and comfort, but it is not the priority immediately following an amniotomy.

B. Monitoring the client's temperature is a consideration but is not the priority immediately following an amniotomy. Assessing the fetal well-being takes precedence.

C. Assessing the fetal heart rate is the priority action.

Following an amniotomy, there is a risk of cord prolapse or compression, and assessing the fetal heart rate helps detect any signs of fetal distress or compromise.

D. Assessing the odor of the amniotic fluid may be relevant, but it is not the immediate priority after an amniotomy. Focusing on fetal well-being is crucial.

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A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make to the client?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is C

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