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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?

A.

Maintain the client in the lithotomy position.

B.

Encourage the client to empty her bladder every 2 hr.

C.

Remind the client to bear down with each contraction.

D.

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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Related Questions

Correct Answer is D

Explanation

Choice A: "I should not drink alcoholic beverages during my pregnancy." Correct, as alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders and other adverse outcomes.
Choice B: "I should drink about 2 liters of fluid each day." Correct, as adequate hydration is essential during pregnancy.
Choice C: "I can have a moderate amount of caffeine daily." Correct, as moderate caffeine consumption is generally considered safe during pregnancy (around 200300 mg per day).
Choice D: During pregnancy, certain fish types can be high in mercury, which can be harmful to the developing fetus. Fish with high mercury levels should be limited or avoided during pregnancy.

Correct Answer is D

Explanation

The correct answer is: April 11, 2016

Choice A: April 27, 2016

Reason: Using Naegele’s Rule, the estimated date of delivery (EDD) is calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). For an LMP of May 4, 2015:

  • Add one year: May 4, 2016
  • Subtract three months: February 4, 2016
  • Add seven days: February 11, 2016

April 27, 2016, is incorrect because it does not follow the correct calculation steps.

Choice B: April 11, 2016

Reason: Following Naegele’s Rule:

  • Add one year: May 4, 2016
  • Subtract three months: February 4, 2016
  • Add seven days: February 11, 2016

April 11, 2016, is the correct EDD as it accurately follows the calculation steps.

Choice C: February 27, 2016

Reason: This date is incorrect because it does not follow the correct calculation steps of Naegele’s Rule. The correct EDD should be in April, not February.

Choice D: February 11, 2016

Reason: This date is also incorrect. While it follows the initial steps of Naegele’s Rule, it does not account for the full calculation, which should result in an April date, not February.

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