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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Endurance: Refers to the ability to withstand pain over time.
B. Level: Refers to the intensity of pain but not the minimum sensation.
C. Tolerance: Refers to the maximum level of pain a person can endure.
D. Threshold: The lowest intensity at which a person perceives a stimulus as painful.
Correct Answer is D
Explanation
A. It reduces the patient’s perception of pain: Expression of pain does not necessarily reduce perception.
B. It is intensified by the vertex position of the fetus: Labor pain may be influenced by fetal position, but the statement is too specific.
C. It can be completely controlled by non-pharmacological techniques: Pain management techniques help but may not eliminate pain.
D. It is influenced by culture: Cultural factors significantly shape how individuals express and perceive pain.
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