A nurse is assisting with the care of a client who is in labor and has the urge to push.
Which of the following instructions should the nurse give the client?
You should push continuously throughout the entire contraction
Take a deep, cleansing breath before and after each contraction
I will let you know when you should push according to your contractions
Hold your breath and push while I count to ten
The Correct Answer is B
Choice A rationale:
Pushing continuously throughout the entire contraction can lead to maternal exhaustion and may not be the most effective way to progress labor. It’s important for the mother to conserve her energy and work with her body’s natural rhythms.
Choice B rationale:
Taking a deep, cleansing breath before and after each contraction can help the mother manage pain and keep her energy up.
This technique is often recommended because it allows the mother to rest briefly and gather strength for the next contraction.
Choice C rationale:
While it’s important for the nurse to monitor contractions and provide guidance, the urge to push is a natural response that
can vary among individuals. Telling the mother when to push according to contractions may not align with her body’s natural
instincts.
Choice D rationale:
Holding one’s breath and pushing while someone counts to ten is an outdated practice. This method can cause unnecessary
strain and doesn’t take into account the individual rhythms and responses of the mother’s body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
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.
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