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Holding one’s breath and pushing while someone counts to ten is an outdated practice.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 C
Explanation
Choice C rationale:
Endometritis is an inflammation of the inner lining of the uterus (endometrium). It is a common complication after childbirth,
affecting up to 1 in 10 women who deliver vaginally. Symptoms of endometritis typically develop within 1-3 days after
childbirth, but they can sometimes take up to a week to appear.
Swelling in the ankles is a common symptom of endometritis. This is because endometritis can cause inflammation and fluid
buildup in the pelvis, which can put pressure on the veins in the legs and cause them to swell.
Choice A rationale:
An increased heart rate can be a symptom of endometritis, but it is not a specific symptom. An increased heart rate can also be
caused by many other factors, such as fever, dehydration, and anxiety.
Choice B rationale:
Decreased appetite can be a symptom of endometritis, but it is not a specific symptom. Decreased appetite can also be caused
by many other factors, such as pain, fatigue, and nausea.
Choice D rationale:
Dry skin is not a typical symptom of endometritis. Dry skin can be caused by many other factors, such as dehydration,
medications, and underlying medical conditions.
Therefore, the most likely manifestation of endometritis in this patient is swelling in the ankles.
Correct Answer is A
Explanation
Choice A rationale:
When breastfeeding, it’s important for the baby to latch onto not just the nipple, but also some of the areola, which is the
darker circle of skin around the nipple. This allows the baby to get a deep latch, which is necessary for effective breastfeeding.
The baby’s chin should be firmly touching the breast, and their mouth should be wide open. When they attach, you should see
much more of the darker nipple skin above the baby’s top lip than below their bottom lip.
Choice B rationale:
While it’s true that babies have certain instincts when it comes to breastfeeding, they still need guidance and proper
positioning to latch correctly. Simply relying on the baby’s instincts may not ensure a proper latch, which could lead to
ineffective breastfeeding and potential discomfort for the mother.
Choice C rationale:
The size of the baby’s mouth does not determine how much of the nipple they should take in. Regardless of the size of the
baby’s mouth, they should still latch onto the nipple and some of the areola for effective breastfeeding. Taking only part of the
nipple could lead to a shallow latch, which can cause nipple pain and may not allow the baby to get enough milk.
Choice D rationale:
While it’s important for the baby to take in a good amount of the breast tissue, including the nipple and areola, during
breastfeeding, suggesting to include some breast tissue beyond the areola might be excessive. The key is to ensure a deep
latch, which typically involves the nipple and some of the areola, rather than the entire areola and additional breast tissue.
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