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.".

Answer and Explanation

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.

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Correct Answer is A

Explanation

Step 1 is assessing heart rate. A heart rate of 130/min earns 2 points since a rate above 100/min is optimal.

Step 2 is assessing respiratory effort. A lusty cry earns 2 points as strong crying indicates good respiratory function.

Step 3 is assessing muscle tone. Flexed extremities earn 1 point since full active movement would score 2.

Step 4 is assessing reflex irritability. Grimace when suctioned earns 1 point as a vigorous response (cough, sneeze) would score 2.

Step 5 is assessing color. Acrocyanosis earns 1 point since a fully pink body scores 2.

Final answer: 7

A. "Given too soon, epidural anesthesia will delay rupture of fetal membranes.". B. "Given too soon, epidural anesthesia can prolong labor.". C. "Given too soon, epidural anesthesia can cause fetal depression.". D. "Given too soon, epidural anesthesia can cause maternal hypertension.".

Correct Answer is B

Explanation

Choice A reason:
Initiating epidural anesthesia too soon may delay rupture of fetal membranes. This statement is not accurate. Epidural anesthesia itself does not have a direct impact on the rupture of fetal membranes. The timing of rupturing membranes is determined based on the progress of labor and other clinical indications. There is no causal relationship between epidural anesthesia and the timing of membrane rupture.

Choice B reason:
Initiating epidural anesthesia too soon can prolong labor. This statement is correct. Epidural anesthesia, while providing pain relief during labor, can also cause some degree of motor blockage and decrease the woman's ability to push effectively. This can potentially lead to a lengthening of the labor process. It is generally recommended to wait until a good labor pattern has been established to avoid unnecessary prolongation of labor.

Choice C reason:
Initiating epidural anesthesia too soon can cause fetal depression. This statement is not entirely accurate. Epidural anesthesia can cross the placenta and reach the fetus, but the effect on the baby is usually minimal. However, fetal monitoring is essential during labor to ensure the baby's well-being, regardless of whether epidural anesthesia is used or not.

Choice D reason:
Initiating epidural anesthesia too soon can cause maternal hypertension. This statement is not supported by evidence. Epidural anesthesia does not typically cause maternal hypertension. It can, however, lead to a decrease in blood pressure in some cases, which is why careful monitoring of maternal blood pressure is necessary during and after the administration of epidural anesthesia.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse include?

Correct Answer is B

Explanation

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