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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Drinking the glucose solution 2 hours prior to the test is not standard for a 1-hour GTT. Instead, the glucose solution is usually consumed within a short timeframe, such as 5 minutes, and the blood is drawn 1 hour afterward.
Choice B Reason:
Limiting carbohydrate intake for 3 days prior to the test is not a requirement for a 1-hour GTT. However, it may be advised for a longer fasting period or a different type of glucose tolerance test.
Choice C Reason:
C. “A blood glucose of 130 to 140 is considered a positive screening result.”
In the 1-hour glucose tolerance test during pregnancy, a blood glucose level of135 mg/dL or higheris considered a positive screening result. If this threshold is met, further testing (such as the 3-hour glucose tolerance test) is recommended to confirm or rule out gestational diabetes.
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Choice D Reason:
Fasting for 12 hours prior to the test is inappropriate. For a 1-hour GTT, the client is not typically required to fast.
Correct Answer is B
Explanation
The correct answer is B. Administer a 500 mL bolus of 5% dextrose in water prior to induction.
A. Informing the client that the anesthetic effect will last for approximately 6 hours is not the nurse's responsibility. The anesthesia provider usually communicates this information to the client.
B. Administering a 500 mL bolus of 5% dextrose in water prior to induction is the correct action.
This helps prevent maternal hypotension, which can be a side effect of epidural analgesia. The fluid bolus helps maintain adequate blood pressure for both the mother and the baby.
C. Having the client stand at the bedside with her arms at her side is not necessary for the administration of epidural analgesia. The client is usually positioned sitting up or lying on her side during the procedure.
D. Obtaining a 30-minute electronic fetal monitoring (EFM) strip prior to induction is not a standard requirement for epidural analgesia. However, continuous fetal monitoring is typically initiated after the epidural is placed to assess the baby's well-being during labor.
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