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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Related Questions
Correct Answer is C
Explanation
A. Administer oxygen using a non-rebreather mask: Oxygen may be helpful later, but positioning improves uteroplacental perfusion first.
B. Elevate the client’s legs: This addresses maternal hypotension but is less effective for repositioning uterine pressure.
C. Place the client in the lateral position: Lateral positioning improves uteroplacental blood flow and is the priority intervention for late decelerations.
D. Increase the rate of the maintenance IV infusion: Increasing fluids may help, but positioning should be done first.
Correct Answer is D
Explanation
A. The fetus is in distress: Fetal distress often presents as decelerations or an abnormal baseline heart rate, not accelerations.
B. The mother is in severe pain: Maternal pain does not cause fetal heart accelerations.
C. Uteroplacental insufficiency: This condition is associated with late decelerations, not accelerations.
D. A well-oxygenated fetus: FHR accelerations indicate adequate oxygenation and a reactive, healthy fetal status.
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