A nurse is assisting with the care of a client who is at 7 cm of cervical dilation and 100% effacement, and in active
labor.
The client informs the nurse that she needs to push.
Which of the following is the appropriate action for the nurse to take?
Have the client pant during the next few contractions
Help the client to the bathroom to empty her bladder
Assist the client into a comfortable position
Assess the perineum for signs of crowning .
The Correct Answer is D
Rationale for Choice A:
Having the client pant during the next few contractions is not appropriate at this time. While panting can be a helpful
breathing technique during earlier stages of labor, it is not recommended when the client feels the urge to push.
Panting can actually delay the progress of labor by preventing the client from bearing down effectively.
It is important to allow the client to push when she feels the urge, as this will help to facilitate the descent of the fetal head and
progress labor.
Rationale for Choice B:
Helping the client to the bathroom to empty her bladder is not the priority action at this time. While a full bladder can
sometimes interfere with labor progress, it is more important to assess the perineum for signs of crowning before taking the
client to the bathroom.
If the fetal head is crowning, it is crucial to avoid any unnecessary delays in delivery.
Rationale for Choice C:
Assisting the client into a comfortable position is important for labor progress, but it is not the priority action at this time.
Assessment of the perineum for signs of crowning takes precedence, as it will guide the nurse's subsequent actions.
Once crowning is confirmed, the nurse can then help the client into a position that facilitates pushing, such as squatting, semi-
sitting, or side-lying.
Rationale for Choice D:
Assessing the perineum for signs of crowning is the most appropriate action for the nurse to take in this situation.
Crowning is the term used to describe the appearance of the fetal head at the vaginal opening.
It is a definitive sign that the client is in the second stage of labor and that delivery is imminent.
By assessing for crowning, the nurse can confirm the progress of labor and prepare for the delivery of the baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Swelling in both breasts is a common finding in breastfeeding women, especially in the early postpartum period. It is often due
to engorgement, which is caused by an oversupply of milk and/or infrequent milk removal.
While engorgement can sometimes lead to mastitis, it is not a definitive sign of the condition.
Other causes of bilateral breast swelling, such as milk stasis or plugged ducts, should also be considered.
Choice B rationale:
Cracked and bleeding nipples can be a symptom of mastitis, but they are not always present.
They can also be caused by other factors, such as improper latch, thrush, or dry skin.
It is important to assess for other signs and symptoms of mastitis, such as fever, chills, and breast tenderness, to make a
definitive diagnosis.
Choice C rationale:
A red and painful area in one breast is a classic sign of mastitis.
This is typically caused by inflammation of the breast tissue, often due to a bacterial infection.
The redness and pain are usually localized to the affected area, and may be accompanied by warmth, swelling, and firmness.
Choice D rationale:
An increase in breast milk production is not a sign of mastitis.
In fact, it is often a sign that breastfeeding is going well.
However, if the milk is not being removed effectively, it can lead to engorgement and blocked ducts, which can increase the
risk of mastitis.
Correct Answer is C
Explanation
Choice C rationale:
Endometritis is an inflammation of the inner lining of the uterus (endometrium). It is a common complication after childbirth,
affecting up to 1 in 10 women who deliver vaginally. Symptoms of endometritis typically develop within 1-3 days after
childbirth, but they can sometimes take up to a week to appear.
Swelling in the ankles is a common symptom of endometritis. This is because endometritis can cause inflammation and fluid
buildup in the pelvis, which can put pressure on the veins in the legs and cause them to swell.
Choice A rationale:
An increased heart rate can be a symptom of endometritis, but it is not a specific symptom. An increased heart rate can also be
caused by many other factors, such as fever, dehydration, and anxiety.
Choice B rationale:
Decreased appetite can be a symptom of endometritis, but it is not a specific symptom. Decreased appetite can also be caused
by many other factors, such as pain, fatigue, and nausea.
Choice D rationale:
Dry skin is not a typical symptom of endometritis. Dry skin can be caused by many other factors, such as dehydration,
medications, and underlying medical conditions.
Therefore, the most likely manifestation of endometritis in this patient is swelling in the ankles.
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