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 A
Explanation
Choice A rationale:
2+ patellar reflex: A hyperactive patellar reflex (also known as a knee-jerk reflex) is a sign of hyperreflexia, which can be a neurological symptom of preeclampsia. Hyperreflexia results from heightened nerve excitability and can manifest as exaggerated reflexes. In preeclampsia, it stems from central nervous system irritability due to cerebral edema or other neurological disturbances.
2+ proteinuria: Proteinuria, defined as the presence of excessive protein in the urine, is a hallmark sign of preeclampsia. It indicates glomerular damage in the kidneys, leading to protein leakage into the urine. The degree of proteinuria is graded on a scale of 1+ to 4+, with 2+ representing a significant level that warrants immediate attention.
Choice B rationale:
24 weeks of gestation: While 24 weeks of gestation is considered early preterm birth, it is not inherently a finding that requires immediate reporting to the RN in the context of postpartum care. The focus on the postpartum unit is primarily on the health of the mother and newborn after delivery, rather than managing ongoing pregnancies.
Choice C rationale:
Preeclampsia: While preeclampsia is a serious condition that necessitates close monitoring and management, the mere diagnosis of preeclampsia without additional concerning findings does not automatically require immediate reporting to the RN. It's essential to assess for specific signs and symptoms that indicate worsening or complications of preeclampsia, such as those mentioned in Choice A.
Choice D rationale:
Heart rate of 100/min: A heart rate of 100 beats per minute is within the normal range for adults, even postpartum. Mild tachycardia (increased heart rate) can be a physiological response to various factors such as pain, anxiety, or exertion, and it does not always signify a serious problem. However, if the heart rate is persistently elevated or accompanied by other concerning symptoms, it would warrant further evaluation.
Correct Answer is C
Explanation
The correct answer is choice c. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.
Choice A rationale:
This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages.
Choice B rationale:
This choice correctly states the cervix is dilated 3 cm and effaced 30%, but it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.
Choice C rationale:
This choice correctly states that the cervix is dilated 3 cm, effaced 30%, and the presenting part is 1 cm above the ischial spines. This matches the documentation provided.
Choice D rationale:
This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages. Additionally, it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.
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