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.
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Accelerations: These are usually a good sign and indicate that the fetus is well-oxygenated.
B. Late decelerations: These are a sign of uteroplacental insufficiency, not a problem with the umbilical cord. They occur when the blood supply to the placenta is reduced during contractions, leading to a decrease in oxygen supply to the fetus.
C. Variable decelerations: This is the correct choice. Variable decelerations can be an indication of umbilical cord compression. They are called “variable” because they can occur at any time during the contraction cycle and can vary in depth and duration.
D. Early decelerations: These are usually benign and are often associated with fetal head compression during contractions, not a problem with the umbilical cord.
Correct Answer is D
Explanation
A. Headache for 30 min: While a headache can be a side effect of magnesium sulfate, it is not typically a critical concern that needs to be reported immediately. However, persistent or severe headaches should be reported.
B. Fetal heart rate 158/min: This is within the normal range for a fetal heart rate (110-160 beats per minute), so it would not typically need to be reported.
C. Respirations 16/min: This is within the normal range for adult respiratory rate (12-20 breaths per minute), so it would not typically need to be reported.
D. Urinary output 40 mL in 2 hours: This is the correct answer. A urinary output of less than 30 mL/hr. may indicate renal insufficiency, which can be a serious side effect of magnesium sulfate therapy. This should be reported to the provider immediately.
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