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 A
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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Related Questions
Correct Answer is D
Explanation
Choice A rationale :
Contractions every 3 to 4 minutes. Rationale: Contractions are a significant sign of labor. When the uterus contracts regularly and with increasing intensity, it indicates that the woman is in labor. However, contractions alone may not be enough to confirm active labor, as Braxton Hicks contractions can occur earlier in pregnancy, which are often irregular and less intense.
Choice B rationale
Pain just above the navel. Rationale: Pain above the navel is not a specific indicator of labor. In late pregnancy, the baby's head may engage in the pelvis, causing pressure and discomfort in the upper abdomen. However, this symptom alone does not confirm active labor and can be attributed to various other factors as well.
Choice C rationale
Amniotic fluid in the vaginal vault. Rationale: The presence of amniotic fluid in the vaginal vault, also known as rupture of membranes or "water breaking,”. is a significant sign that labor is likely to be in progress or imminent. When the amniotic sac ruptures, it releases the fluid that surrounds the baby in the uterus. This is a clear indication of active labor.
Choice D rationale
Cervical dilation. Rationale: Cervical dilation is one of the most reliable signs of active labor. As the uterus contracts, the cervix starts to dilate and efface (thin out) to allow the baby's passage through the birth canal. Measuring cervical dilation during a pelvic examination provides valuable information about the progress of labor.
Correct Answer is C
Explanation
Choice A rationale:
This statement is incorrect because Rho(D) immune globulin does not destroy Rh antibodies in a newborn who is Rh-positive. Instead, it acts to prevent the development of Rh antibodies in the mother.
Choice B rationale:
This statement is also incorrect. Rho(D) immune globulin does not destroy Rh antibodies in a woman who is Rh-negative. It is given to Rh-negative women to prevent them from forming Rh antibodies in response to Rh-positive fetal blood during pregnancy.
Choice C rationale:
This is the correct choice. Rho(D) immune globulin is given to Rh-negative women to prevent the formation of Rh antibodies. If an Rh-negative woman is exposed to Rh-positive blood (usually during childbirth), her immune system may recognize the Rh antigen as foreign and start producing Rh antibodies. These antibodies could potentially cross the placenta during a subsequent pregnancy and attack the red blood cells of an Rh-positive fetus, causing hemolytic disease in the newborn. Rho(D) immune globulin helps prevent this sensitization process.
Choice D rationale:
This statement is incorrect. Rho(D) immune globulin does not prevent the formation of Rh antibodies in a newborn who is Rh-positive. Its main purpose is to protect Rh-negative women from forming antibodies that could harm future Rh-positive pregnancies.
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