How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.
 


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

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

A) Administer oxygen using a nonrebreather mask: While oxygen may be necessary if there are signs of fetal distress, the priority action in this situation is to reposition the client and relieve potential cord compression.
B) Elevate the client's legs: Elevating the client's legs is not the most appropriate action in this situation and may not address the cause of the decelerations.
C) Place the client in the lateral position: This is the correct answer. The described pattern of the fetal heart rate (slowdown after the start of a contraction with the lowest rate occurring after the peak of the contraction) suggests late decelerations, which are often caused by uteroplacental
insufficiency or cord compression. Placing the client in the lateral position can help alleviate potential compression of the umbilical cord and improve fetal oxygenation.
D) Increase the rate of maintenance IV infusion: Increasing the IV infusion rate may not be the most appropriate action for late decelerations. Repositioning the client is the priority in this situation.

Correct Answer is B

Explanation

Choice A reason:

Monitoring weight gain is correct because appropriate weight gain helps support fetal growth and reduces risks of complications such as gestational diabetes and preeclampsia.

Choice B reason:

Using nonprescription medications without provider approval is unsafe since many over-the-counter drugs (like NSAIDs or decongestants) can harm the fetus. This shows a need for further teaching.

Choice C reason:

Telling the provider before using home remedies is appropriate, as some herbs or supplements may be unsafe in pregnancy.

Choice D reason:

Reducing stress is correct because high maternal stress can negatively affect pregnancy outcomes and fetal development.

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

Register