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?

Maintain the client in the lithotomy position.

Encourage the client to empty her bladder every 2 hr.

Remind the client to bear down with each contraction.

Perform vaginal examinations frequently,

Answer and Explanation

The Correct Answer is B

A. Maintain the client in the lithotomy position: The lithotomy position is not typically

maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B.   Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C.   Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D.   Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.

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Correct Answer is A

Explanation

Choice A:The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
Choice B: Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
Choice C: Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
Choice D: Palpating the client's uterus is not the first priority in the presence of late

decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.

A. Administer glucocorticoids intramuscularly. B. Prepare the client for emergency cesarean section. C. Assess the odor of the amniotic fluid. D. Recheck the client's temperature in 4 hr.

Correct Answer is C

Explanation

A: Administering glucocorticoids intramuscularly is indicated for enhancing fetal lung maturity in cases of anticipated preterm birth. However, the client is at 38 weeks of gestation, which is not considered preterm, and the elevated temperature is the main concern.
B: Preparing the client for an emergency cesarean section based solely on an elevated temperature is not an appropriate action. There may be other factors contributing to the temperature elevation, and further assessment is needed.

C: An elevated temperature during pregnancy can indicate infection, which is a concern when the client's membranes have ruptured (premature rupture of membranes or PROM). Before any
interventions are initiated, the nurse should assess the odor of the amniotic fluid as it can provide important information about possible infection. If the amniotic fluid has a foul odor or appears
cloudy, it may indicate infection and require prompt medical attention.

D: Rechecking the client's temperature in 4 hours is not the appropriate immediate action when an elevated temperature is observed, especially in a pregnant woman.

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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 in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

Correct Answer is C

Explanation

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