A nurse is caring for a client who is about to deliver a baby.
Which of the following responses should the nurse make?
The nurse should prepare for a cesarean birth
The nurse should check the client’s temperature every 8 hours
The nurse should encourage the client to empty the bladder every 2 hours
The nurse should remind the client to bear down with each contraction
The Correct Answer is D
Choice A rationale:
Cesarean birth is a surgical procedure that is only performed when there is a medical indication for it. It is not the standard of
care for all women who are about to deliver a baby.
In the absence of any specific information indicating a need for cesarean birth, it would be premature for the nurse to prepare
for one.
Choice B rationale:
Checking the client's temperature every 8 hours is part of routine postpartum care.
However, it is not a priority intervention during the active labor phase when the client is about to deliver.
The nurse's focus should be on supporting the client through the delivery process.
Choice C rationale:
Encouraging the client to empty the bladder every 2 hours is important for comfort and to prevent urinary retention.
However, it is not a priority intervention during the active labor phase.
The client may not feel the urge to urinate frequently due to the pressure of the baby's head on the bladder.
Choice D rationale:
Reminding the client to bear down with each contraction is the most appropriate nursing intervention at this time.
Bearing down helps to move the baby down the birth canal and can shorten the duration of labor.
The nurse can provide verbal cues and physical support to help the client bear down effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Stopping breastfeeding until the antibiotics are done is not a recommended practice. Most antibiotics are safe to use while
breastfeeding. Moreover, stopping breastfeeding can lead to engorgement.
Choice B rationale:
Applying cold compresses 20 minutes before each feeding is not a recommended practice. Cold compresses are usually
recommended after breastfeeding to help reduce swelling. Warm compresses or taking a warm shower before breastfeeding
can help increase milk flow and promote the letdown reflex.
Choice C rationale:
Feeding the baby every 2 hours is a good practice to prevent breast engorgement. Frequent feeding helps to empty the breasts,
which can prevent them from becoming overly full and engorged.
Choice D rationale:
Not wearing a bra during the daytime is not a recommended practice. Wearing a well-fitted bra can provide support and help
reduce discomfort associated with breast engorgement.
Correct Answer is A
Explanation
Choice A rationale:
Oxytocin is a hormone that causes the uterus to contract. It is often given to women after childbirth to help the uterus return
to its normal size and to prevent heavy bleeding. Therefore, monitoring the consistency of the fundus (the upper part of the
uterus) is an effective way to evaluate the effectiveness of this medication.
Choice B rationale:
While urinary output is an important vital sign to monitor in all patients, it is not directly related to the effectiveness of
Oxytocin. Oxytocin does not have a significant effect on urinary output.
Choice C rationale:
Blood pressure is another vital sign that should be monitored in all patients. However, it is not the primary indicator of
Oxytocin’s effectiveness. While Oxytocin can cause blood pressure changes, these are usually transient and not the primary
intended effect of the medication.
Choice D rationale:
Heart rate, like blood pressure and urinary output, is an important vital sign to monitor in all patients. However, it is not the
primary indicator of Oxytocin’s effectiveness. Oxytocin does not have a significant direct effect on heart rate.
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