A nurse is caring for a client following an amniotomy, who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Encourage the client to empty her bladder every 2 hr.

Remind the client to bear down with each contraction.

Maintain the client in the lithotomy position.

Perform vaginal examinations frequently.

Answer and Explanation

The Correct Answer is A

A. Encourage the client to empty her bladder every 2 hr.: This is the correct choice. A full bladder can impede the descent of the fetus and can increase the client’s discomfort. Therefore, it’s important to encourage the client to empty her bladder regularly.
B. Remind the client to bear down with each contraction: This is not recommended during the active phase of the first stage of labor. The client should be instructed to bear down only during the second stage of labor when the cervix is fully dilated.
C. Maintain the client in the lithotomy position: This is not necessary during the active phase of the first stage of labor. The lithotomy position is typically used during the second stage of labor for the actual delivery of the baby. During the first stage, the client should be encouraged to find a comfortable position.
D. Perform vaginal examinations frequently: This is not recommended. Frequent vaginal examinations increase the risk of introducing infection. Vaginal examinations should be performed only when necessary to assess the progress of labor.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Assist the client to turn onto her side: This is the correct choice. The client’s blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava, reducing venous return to the heart and lowering blood pressure. Turning the client onto her side, preferably the left side, can relieve this compression and improve blood flow and blood pressure.

B. Assist the client to an upright position: This is not the first action to take. While an upright position can sometimes help with progression of labor, it might not help with the client’s low blood pressure.

C. Prepare for an immediate vaginal delivery: This is not indicated based solely on the information given. The client’s cervical dilation, effacement, and blood pressure do not indicate that immediate delivery is necessary.

D. Prepare for a cesarean birth: This is not indicated based solely on the information given. The client’s cervical dilation, effacement, and blood pressure do not indicate that a cesarean birth is necessary.

A. "Have you spoken to your mother about these feelings’’ B. "Perhaps you should see a counsellor to discuss these feelings further” C. "Ambivalent feelings are quite common for women early in pregnancy” D. "Don't worry. You will be fine once the baby is born”

Correct Answer is C

Explanation

A. "Have you spoken to your mother about these feelings’’: While family support can be helpful, it’s not the nurse’s place to suggest who the client should talk to about her feelings. Each person’s support system is unique and personal.

B. "Perhaps you should see a counsellor to discuss these feelings further”: While professional help can be beneficial, suggesting it as the first response may make the client feel that her feelings are abnormal or something to be concerned about.

C. "Ambivalent feelings are quite common for women early in pregnancy”: This is the correct choice. It’s important to normalize the client’s feelings. Pregnancy, especially the first one, is a significant life event filled with changes. It’s completely normal to have mixed feelings and doubts.

D. “Don’t worry. You will be fine once the baby is born”: This response dismisses the client’s feelings and concerns. It’s important to validate the client’s feelings rather than minimizing them. Every person’s experience with pregnancy and parenthood is unique, and it’s not helpful to make assumptions about how the client will feel in the future.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client following an amniotomy, who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord. Which of the following actions should the nurse perform first?

A nurse is caring for a new mother who is concerned that her newborns eyes cross. Which of the following statements is a therapeutic response by the nurse?

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client’s blood pressure is 80/40mmHg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal discharge. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply)

A nurse is caring for a client following an amniotomy, who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?