A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?
Observe for the presence of a nuchal cord.
Prepare to administer oxytocin.
Observe for crowning.
Apply fundal pressure.
The Correct Answer is C
A. Observe for the presence of a nuchal cord: While this is important, it is not specifically related to the finding of the fetal head at a certain station.
B. Prepare to administer oxytocin: Oxytocin is a hormone used to induce or augment labor, but there is no indication for its use based solely on the fetal head station.
C. Observe for crowning: The fetal head at 3+ station indicates significant descent, and crowning may occur soon. Crowning is the appearance of the fetal head at the vaginal opening and indicates that delivery is imminent.
D. Apply fundal pressure: Fundal pressure is not appropriate at this stage of labor and could cause harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Late decelerations in the fetal heart rate are often associated with uteroplacental insufficiency, and one of the first interventions is to improve uterine blood flow by changing the client's position. Placing the client in a left lateral position can help relieve pressure on the vena cava and improve blood flow to the placenta and the baby.
Choice B: Administering oxygen is a correct intervention for late decelerations, but it should follow the position change. Oxygen administration helps increase oxygen levels in the maternal blood, which can improve fetal oxygenation.
Choice C: Applying a fetal scalp electrode can provide continuous fetal heart rate monitoring, but it does not address the immediate concern of late decelerations. Position change and oxygen administration should be the priority.
Choice D: Increasing the rate of the IV infusion might not have an immediate effect on resolving late decelerations. Position change and oxygen administration should be the initial interventions.
Correct Answer is A
Explanation
Choice A: Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which play a crucial role during childbirth. Strengthening these muscles can aid in better control during labor and delivery, facilitating stretching and reducing the risk of injury.
Choice B: Kegel exercises do not have a direct impact on preventing constipation during pregnancy. However, they may help improve bowel control and prevent fecal incontinence.
Choice C: While Kegel exercises can improve posture and core strength, their primary benefit lies in strengthening the pelvic muscles, not directly reducing backaches throughout pregnancy.
Choice D: Kegel exercises are not intended to prevent stretch marks on the abdomen. Stretch marks are caused by the stretching of the skin during pregnancy and are not related to pelvic muscle exercises.
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