A nurse is caring for a client who was in the first stage of labor and is encouraging the client to void every two hours. Which of the following statements should the nurse make?

A distended bladder will be traumatized by frequent pelvic exams

A distended bladder reduces pelvic space needed for birth.

A full bladder increases the risk for fetal trauma trauma

A full bladder increases the risk for bladder infections

Answer and Explanation

The Correct Answer is B

The correct answer is B. A distended bladder reduces pelvic space needed for birth.

A. A distended bladder itself is not typically traumatized by pelvic exams. However, a full bladder can impede the progress of labor and may affect the accuracy of pelvic exams.

B. This statement is accurate. A distended bladder can reduce the available pelvic space needed for the descent of the baby during labor. An empty bladder allows the fetal head to engage more easily in the pelvis.

C. A full bladder is not directly associated with an increased risk for fetal trauma. The primary concern is the impact on pelvic space and the progress of labor.

D. While a full bladder can contribute to urinary tract infections, it is not the primary reason for encouraging the client to avoid a distended bladder during labor.

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Correct Answer is A

Explanation

A. Correct. In rapidly progressing labor, applying gentle perineal pressure helps control the speed of delivery and can prevent or minimize perineal tearing or lacerations. It also helps to manage the delivery of the fetal head, especially in cases where the labor is very rapid which can cause neurologic damage (increased intracranial pressure and dural/subdural tearing).

B. Cutting the umbilical cord is not the priority in this situation. The focus should be on the immediate management of the delivery process and preventing complications related to perineal tearing.

C. Preventing the perineum from tearing: While preventing the perineum from tearing is important, it is not the immediate priority in the context of rapidly progressing labor. The primary focus should be on safely delivering the baby, which involves controlling the delivery of the fetal head to prevent complications.

D. Promoting the delivery of the placenta is a consideration for the third stage of labor, which follows the delivery of the baby. It is not the priority during the active phase of delivery.

A. "You should replace the diaphragm every 5 years." B. "You should leave the diaphragm in place for at least 6 hours after intercourse." C. "You should use an oil-based product as a lubricant when inserting the diaphragm." D. "You should insert the diaphragm when your bladder is full."

Correct Answer is B

Explanation

Choice A Reason:

"You should replace the diaphragm every 5 years." This statement is inappropriate. Diaphragms typically need replacement more frequently than every 5 years. The lifespan of a diaphragm is usually shorter, and it may need to be replaced every 1 to 2 years, depending on the material and condition.

Choice B Reason:

"You should leave the diaphragm in place for at least 6 hours after intercourse." This statement is appropriate. Leaving the diaphragm in place for at least 6 hours after intercourse helps ensure its effectiveness in preventing pregnancy. Removing it too soon may increase the risk of sperm reaching the cervix.

Choice C Reason:

"You should use an oil-based product as a lubricant when inserting the diaphragm. "This statement is inappropriate. Oil-based lubricants can damage latex diaphragms. Water-based or silicone-based lubricants are recommended instead.

Choice D Reason:

"You should insert the diaphragm when your bladder is full." This statement is inappropriate. There is no specific need to insert the diaphragm when the bladder is full. However, emptying the bladder before insertion may make the process more comfortable for the client.

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A nurse is caring for a client who was in the first stage of labor and is encouraging the client to void every two hours. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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