A nurse is assisting with the care of a client who is multigravid and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriate nursing response?
Help the client to the bathroom to empty her bladder.
Assist the client into a comfortable position.
Have the client pant during the next few contractions.
Assess the perineum for signs of crowning.
None
None
The Correct Answer is D
Choice A rationale:
Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labour, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.
Choice B rationale:
Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.
Choice C rationale:
Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labour has commenced. Panting is not necessary at this point.
Choice D rationale:
The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","F"]
Explanation
Choice A rationale:
The nurse should report visual disturbances to the provider. Visual disturbances in a pregnant client could indicate potential complications such as preeclampsia or eclampsia. These conditions are characterized by high blood pressure and can be harmful to both the mother and the fetus. Reporting visual disturbances promptly allows the provider to assess the situation and take appropriate actions to ensure the safety of the client and the baby.
Choice B rationale:
The nurse should also report blood pressure changes to the provider. The client's blood pressure has increased significantly from 179/99 mm Hg to 170/101 mm Hg over a short period. High blood pressure during pregnancy can be indicative of preeclampsia, a serious condition that requires close monitoring and management to prevent complications. Reporting the blood pressure changes promptly allows the provider to evaluate the situation and intervene as needed to safeguard the client's well-being.
Choice F rationale:
The nurse should report the fetal heart rate to the provider. Monitoring the fetal heart rate is crucial in prenatal care as it helps assess the well-being of the baby. Any abnormality in the fetal heart rate could indicate fetal distress or other complications. Promptly reporting any concerning changes in the fetal heart rate enables the provider to take appropriate measures to ensure the health and safety of the baby. The other choices (C, D, and E) are not the most critical findings in this scenario. While respiratory rate (C), deep tendon reflexes (D), and weight (E) are important aspects to monitor during pregnancy, they do not raise immediate concerns for potential complications like visual disturbances, blood pressure changes, and fetal heart rate abnormalities mentioned above. Nonetheless, they should still be documented and monitored regularly as part of routine prenatal care.
Correct Answer is C
Explanation
Choice A rationale:
The client's statement, "I need to schedule the test when the baby is usually active,”. is accurate and demonstrates a good understanding of the nonstress test (NST). The NST is typically performed to assess the baby's heart rate and movements when they are active, which provides better insights into the baby's well-being.
Choice B rationale:
The client's statement, "The baby's heart rate will be monitored during the test,”. is correct and indicates a solid grasp of the purpose of the NST. During the test, the baby's heart rate is continuously monitored to assess their overall well-being and any signs of distress.
Choice C rationale:
This is the correct answer. The client's statement, "I will have to lie on my back during the test,”. indicates a need for further teaching. In an NST, pregnant individuals are usually asked to lie on their left side, not on their back. The left lateral position enhances blood flow to the placenta and the baby, making it the preferred position for this test.
Choice D rationale:
The client's statement, "I will be able to go to the bathroom during the test as necessary,”. is accurate and demonstrates a good understanding of the NST procedure. Unlike some other prenatal tests, NST allows pregnant individuals to change positions, including using the bathroom if needed, to ensure their comfort during the monitoring process.
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