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.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Heavy vaginal bleeding in late pregnancy, especially at 39 weeks of gestation, is a medical emergency that requires immediate
intervention.
It can be a sign of placental abruption, a serious condition in which the placenta separates from the uterine wall prematurely.
Placental abruption can lead to fetal distress and maternal hemorrhage, both of which can be life-threatening.
Cesarean birth is the quickest and safest way to deliver the baby in this situation.
It allows the healthcare team to control the bleeding and prevent further complications.
Delaying a cesarean birth can put the mother and baby at increased risk.
Choice B rationale:
Antibiotics are not indicated for heavy vaginal bleeding in late pregnancy.
They are used to treat infections, not bleeding.
There is no evidence to suggest that the client has an infection.
Choice C rationale:
Magnesium sulfate is a medication used to prevent seizures in women with preeclampsia.
It is not indicated for heavy vaginal bleeding.
There is no evidence to suggest that the client has preeclampsia.
Choice D rationale:
A cervical examination is not necessary in this situation.
The priority is to deliver the baby as quickly as possible.
A cervical examination would only delay the delivery.
Correct Answer is A
Explanation
Choice A rationale:
A full bladder can displace the uterus to the right and interfere with its ability to contract properly. This can lead to
postpartum hemorrhage, a serious complication that can occur after childbirth.
Emptying the bladder helps to reposition the uterus in the midline and allows it to contract more effectively. This helps to
prevent postpartum hemorrhage and promotes uterine involution, the process by which the uterus returns to its pre-
pregnancy size.
In this case, the client's fundus is firm, which indicates that it is contracting well. However, it is slightly deviated to the right,
which suggests that the bladder may be full.
Asking the client to empty her bladder is a simple and effective way to address this potential problem.
Choice B rationale:
Repeating the client's temperature evaluation is not a priority action in this case. The client's vital signs are within normal
limits, and there is no indication of infection.
A temperature elevation could be a sign of infection, but it is not the most likely cause of the uterine deviation in this case.
Choice C rationale:
Encouraging the client to nurse more frequently may be helpful in stimulating milk production and uterine contractions.
However, it is not the most immediate priority in this case.
The client's breasts are soft, which suggests that she is not yet producing a significant amount of milk.
The priority is to address the potential problem of a full bladder, which could interfere with uterine involution.
Choice D rationale:
Checking for signs of a urinary tract infection is not a priority action in this case. The client does not have any urinary
symptoms, such as dysuria or frequency.
A urinary tract infection could cause a uterine deviation, but it is not the most likely cause in this case.
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