A nurse is assisting in the care of a client in labor who states, "I am really afraid of giving birth," and begins crying.
The client is currently in active labor and vaginal exam reveals 7 cm dilation, 80% effacement, and 0 station. Which of the following factors of labor should the nurse identify as needing addressed at this time?
Passageway.
Passenger.
Psyche.
Powers.
The Correct Answer is C
Choice A rationale
The passageway refers to the birth canal, including the pelvis and soft tissues. While an adequate passageway is essential for labor progression, the client's current cervical dilation (7 cm) and effacement (80%) indicate that the passageway is accommodating fetal descent, and there is no direct evidence from the scenario suggesting an issue with this factor.
Choice B rationale
The passenger refers to the fetus, including its size, presentation, lie, and attitude. There is no information in the scenario to suggest any concerns with the fetus itself, such as malpresentation or distress. The focus of the client's statement is on their emotional state rather than a physical aspect of the baby.
Choice C rationale
Psyche refers to the client's psychological and emotional state during labor. The client's statement "I am really afraid of giving birth" and subsequent crying directly indicate significant fear and anxiety. This emotional distress can negatively impact labor progression by increasing catecholamine release, potentially hindering uterine contractions and increasing pain perception, thus requiring immediate attention.
Choice D rationale
Powers refer to the uterine contractions (primary power) and the mother's pushing efforts (secondary power). While effective powers are crucial for labor progression, the scenario does not provide information to suggest that the client's contractions are inadequate or that there's an issue with her ability to push. The immediate concern presented is her emotional state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Increased dietary fiber (cellulose) adds bulk to the stool, promoting peristalsis and facilitating bowel movements. Adequate fluid intake is crucial for softening stool and preventing dehydration, which can exacerbate constipation. Together, these interventions physically aid in the formation and passage of softer, more regular stools, addressing the root cause of pregnancy-related constipation.
Choice B rationale
Regular use of a laxative, especially stimulant laxatives, is generally discouraged during pregnancy due to potential for dependency, electrolyte imbalances, and uterine contractions. While some bulk-forming laxatives might be considered, the primary recommendation focuses on dietary and lifestyle modifications as a safer and more physiological approach to managing constipation.
Choice C rationale
Maintenance of good posture can influence comfort and spinal alignment, but it does not directly address the physiological mechanisms contributing to constipation, such as slowed gastrointestinal motility or insufficient dietary fiber and fluid. While beneficial for overall well-being, it is not a primary intervention for alleviating constipation.
Choice D rationale
Regular use of glycerin suppositories acts as a local irritant and osmotic agent to soften and stimulate the rectum for defecation. While they can provide temporary relief, they do not address the underlying causes of constipation in pregnancy and their regular use can lead to dependency, hindering the body's natural bowel function.
Correct Answer is B
Explanation
Step 1: May 4 is the first day of the last menstrual period.
Step 2: Add 7 days to May 4, which equals May 11.
Step 3: Count back 3 months from May, which leads to February.
Step 4: Therefore, the estimated date of delivery is February 11.
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