A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client?
"Take a deep, cleansing breath before and after each contraction.".
"Hold your breath and push while I count to ten.".
"You should push continuously throughout the entire contraction.".
"I will let you know when you should push according to your contractions.".
The Correct Answer is D
Choice A rationale:
The nurse should not advise the client to take deep, cleansing breaths before and after each contraction because it can interfere with the natural urge to push and may not be effective in helping with the labor process. When a client feels the urge to push, it is essential to work with their body's natural instincts.
Choice B rationale:
Instructing the client to hold their breath and push while counting to ten is not recommended. This Valsalva manoeuvre can cause a sudden increase in intra-abdominal pressure, which may reduce blood flow to the heart and brain and may be harmful to both the client and the baby. It's crucial to promote safe pushing techniques during labor.
Choice C rationale:
The instruction to push continuously throughout the entire contraction is also not ideal. Pushing continuously can lead to exhaustion and decrease the effectiveness of each push. It's essential to guide the client on when and how to push effectively to prevent unnecessary fatigue.
Choice D rationale:
The correct instruction is to let the client know when to push according to their contractions. The urge to push is a natural reflex that signifies the baby's descent into the birth canal. The nurse should encourage the client to listen to their body and push when they feel the urge during the contractions. This approach optimizes the client's efforts and conserves their energy for delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hypotension is not an expected finding in a client with severe preeclampsia. In preeclampsia, the client typically experiences hypertension (high blood pressure) rather than hypotension (low blood pressure). Hypotension may be concerning as it could indicate inadequate perfusion to vital organs.
Choice B rationale:
Headache is an expected finding in a client with severe preeclampsia. Headaches are a common symptom of preeclampsia and are often described as persistent and severe. They can result from increased blood pressure and possibly cerebral oedema.
Choice C rationale:
Tachycardia is not an expected finding in a client with severe preeclampsia. Tachycardia refers to an abnormally fast heart rate, but in preeclampsia, bradycardia (abnormally slow heart rate) or a normal heart rate is more typical. Tachycardia could indicate other underlying issues.
Choice D rationale:
Polyuria is not an expected finding in a client with severe preeclampsia. Polyuria is characterized by excessive urination, and in preeclampsia, the opposite may occur due to decreased kidney perfusion, resulting in oliguria (reduced urine output).
Correct Answer is ["A","B","E"]
Explanation
The correct answers are choices A. Blood pressure, B. Cerebral manifestations, and E. Deep tendon reflexes.
Choice A rationale:
Blood pressure is a critical parameter to monitor, especially in the third trimester. Elevated blood pressure can indicate preeclampsia, a serious condition that requires immediate attention.
Choice B rationale:
Cerebral manifestations, such as headaches or visual disturbances, can also be signs of preeclampsia. These symptoms should be reported to the provider immediately.
Choice C rationale:
The fetal heart rate of 158/min is within the normal range (110-160 beats per minute) and does not need to be reported.
Choice D rationale:
The respiratory rate is not mentioned in the provided notes, and there is no indication that it is abnormal. Therefore, it does not need to be reported.
Choice E rationale:
Deep tendon reflexes that are hyperactive (3+) can be a sign of preeclampsia. This finding should be reported to the provider.
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