A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client
suddenly states that she needs to push. Which of the following actions should the nurse take?
Have the client pant during the next contractions.
Assist the client into a comfortable position.
Help the client to the bathroom to void.
Observe the perineum for signs of crowning
The Correct Answer is A
A Panting helps the client manage the urge to push and prevents premature pushing, which can cause cervical swelling or injury. This technique helps delay pushing until full dilation is achieved, ensuring a safer delivery process.
B. Helping the client into a comfortable position can facilitate labor progress. However, it may not be the most urgent action given the potential imminent delivery.
C. Voiding is a common suggestion during labor, but if the client feels the urge to push, it may be an indication that the baby is descending and delivery is imminent.
D. The client's urge to push indicates that the baby is descending, and birth is imminent. It would not be safe to have the client walk to the bathroom at this stage, as she may deliver the baby during the process, increasing the risk of an unattended birth.
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Related Questions
Correct Answer is C
Explanation
Allowing the baby to drain one breast at each feeding helps ensure effective milk removal, which can alleviate breast engorgement. Emptying the breast thoroughly promotes milk flow and prevents milk stasis, which contributes to engorgement.
A Cold compresses provide temporary relief from discomfort but does not address the underlying cause of engorgement.
B Drinking herbal tea, may have limited evidence supporting its efficacy in reducing engorgement. While hydration is important for breastfeeding, relying solely on herbal tea may not be as effective as other strategies.
D Feeding the baby every 2 hours, is important for maintaining milk supply and preventing engorgement. However, it's essential to ensure the breast is fully drained at each feeding, regardless of the time interval between feedings.
Correct Answer is C
Explanation
A firm, displaced fundus to the right of midline indicates a full bladder. A distended bladder can prevent the uterus from contracting properly and can lead to uterine atony, increasing the risk of postpartum hemorrhage. Therefore, the priority action is to have the client empty her bladder.
This can often be achieved by encouraging the client to urinate or by assisting her with toileting if necessary. Palpating a fundus that is firm and displaced does not indicate the need for fundal massage, as the fundus is already firm. Inserting a urinary catheter may be necessary if the client is unable to void spontaneously, but this should be done after attempting to have the client
urinate voluntarily. Administering an analgesic is not indicated based on the information provided.
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