A nurse is assisting with the care of a client who is multigravida 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 the bladder

Assist the client to a comfortable position

Assess the perineum for signs of crowning

Have the client pant during the next few contractions

Answer and Explanation

The Correct Answer is D

A. Help the client to the bathroom to empty the bladder: It is unsafe to ambulate a client in active labor who feels the urge to push; crowning must first be ruled out.

B. Assist the client to a comfortable position: Comfort is important, but immediate assessment for crowning takes priority to prepare for delivery.

C. Assess the perineum for signs of crowning: While this is an important assessment, the immediate action to take when the client feels the urge to push is to instruct her to pant to prevent premature pushing.

D. Have the client pant during the next few contractions: Panting helps the patient avoid pushing before full dilation is achieved, reducing the risk of complications such as cervical lacerations or fetal distress. This technique helps manage the urge to push until the cervix is fully dilated.

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Correct Answer is C

Explanation

A. Birth of the infant: Marks the end of the second stage of labor.

B. Full cervical dilation: Marks the beginning of the second stage of labor.

C. Expulsion of the placenta and membranes: This defines the completion of the third stage.

D. Engagement of the head: Occurs earlier in labor, typically during the first stage.

A. It can cause medication given at later stages to be ineffective. B. It will have no complications for the mother or infant. C. It may result in respiratory depression to the newborn. D. It will speed up the dilation and effacement.

Correct Answer is C

Explanation

A. It can cause medication given at later stages to be ineffective: This is incorrect; narcotic analgesics do not impact the effectiveness of later medications.

B. It will have no complications for the mother or infant: Narcotic analgesics can have side effects, including respiratory depression in the newborn.

C. It may result in respiratory depression to the newborn: Narcotics given close to delivery can depress the newborn’s respiratory efforts.

D. It will speed up the dilation and effacement: Narcotics do not affect the rate of cervical dilation or effacement.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What marks the end of the third stage of labor?

Correct Answer is C

Explanation

A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. What should the nurse explain regarding giving a narcotic analgesic medication at this stage of labor?

Correct Answer is C

Explanation

A nurse is caring for a client who is reporting severe pain during labor and is no longer wanting to follow their natural birth plan. Which of the following interventions should the nurse recognize as being supportive and appropriate for the partner at the bedside to take? Select all that Apply.

A nurse is assisting with the care of a client who is experiencing preterm labor and is scheduled to undergo amniocentesis. The client needs an amniocentesis to determine which of the following findings?

What is the least amount of sensation that one perceives as pain?

A nurse is assisting with the care of a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief?

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate effectiveness of this medication?

A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?