A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take?
Check the client's temperature every 4 hr.
Remind the client to bear down with each contraction.
Maintain the client in the lithotomy position.
Encourage the client to empty the bladder every 2 hr.
The Correct Answer is D
Choice A reason: Check the client's temperature every 4 hr is incorrect, as this action is not frequent enough for a client who had an amniotomy. The nurse should check the client's temperature every 2 hr after an amniotomy, as there is an increased risk of infection due to the rupture of membranes. The nurse should also monitor for signs of chorioamnionitis, such as foul-smelling amniotic fluid, maternal tachycardia, or fetal tachycardia.
Choice B reason: Remind the client to bear down with each contraction is incorrect, as this action is not appropriate for a client who is in the active phase of the first stage of labor. The nurse should instruct the client to avoid bearing down or pushing until they are in the second stage of labor, when the cervix is fully dilated and effaced. Bearing down too early can cause cervical edema, lacerations, or exhaustion.
Choice C reason: Maintain the client in the lithotomy position is incorrect, as this action is not optimal for a client who is in the active phase of the first stage of labor. The lithotomy position is a supine position with the legs elevated and abducted, which can reduce blood flow to the uterus and placenta, increase perineal edema, and limit pelvic outlet diameter. The nurse should encourage the client to change positions frequently and use upright or lateral positions that can enhance uterine contractility, fetal descent, and maternal comfort.
Choice D reason: Encourage the client to empty the bladder every 2 hr is correct, as this action can promote labor progress and prevent bladder distension and infection. The nurse should assist the client to void every 2 hr after an amniotomy, as there may be decreased sensation of bladder fullness due to pressure from the fetal head. A full bladder can interfere with uterine contractions, fetal descent, and cervical dilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Panting can help prevent premature pushing and reduce the risk of cervical edema or laceration. The client should be instructed to take short, shallow breaths through her mouth during contractions until she reaches 10 cm of dilation.
Choice B reason:
Assessing the perineum for signs of crowning is not a priority at this stage, as the fetus is not yet at a low enough station to be visible. Crowning usually occurs when the fetus is at +4 or +5 station.
Choice C reason:
Assisting the client into a comfortable position is important, but it does not address the urge to push. The client should be encouraged to change positions frequently to promote fetal descent and comfort.
Choice D reason:
Helping the client to the bathroom to empty her bladder is not advisable, as it can increase the risk of cord prolapse or rupture of membranes. The client should have an indwelling catheter inserted if she is unable to void spontaneously.
Correct Answer is B
Explanation
Choice A reason: Perform fundal massage is incorrect, as this action is not indicated for a client who has a firm and midline fundus. Fundal massage is used to stimulate uterine contraction and prevent hemorrhage in clients who have a boggy or deviated fundus.
Choice B reason: Assist the client to ambulate is correct, as this action can promote lochia drainage and prevent pooling of blood in the vagina. The nurse should encourage the client to ambulate early and frequently after birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide assistance as needed.
Choice C reason: Check for blood under the client's butock is incorrect, as this action is not necessary for a client who has a small amount of lochia rubra on the perineal pad. Lochia rubra is normal and expected in the first few days after birth, and it indicates that the placental site is healing. The nurse should check for blood under the butock only if there is suspicion of excessive bleeding or concealed hemorrhage.
Choice D reason: Increase the rate of the IV fluids is incorrect, as this action is not indicated for a client who has a small amount of lochia rubra on the perineal pad. Increasing the rate of IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.
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