The nurse asks a laboring client to lie on her left side. The appropriate rationale for this measure is to:
decrease the heart rate of the fetus
Aid the women while she pushes
prevent supine hypertension
prevent the client from falling out of bed
The Correct Answer is C
A) Decrease the heart rate of the fetus:
Lying on the left side can sometimes help improve fetal oxygenation, especially if there is a concern about reduced blood flow from compression of the inferior vena cava, which can occur when the mother lies on her back. However, the primary rationale for this position is to prevent supine hypotension, not specifically to decrease fetal heart rate. In fact, side-lying can promote better oxygen exchange, which can indirectly benefit the fetal heart rate.
B) Aid the women while she pushes:
While a left-side lying position may offer comfort during labor and can help with uterine positioning, it is not specifically intended to aid in the pushing phase. Positions such as squatting or hands-and-knees are generally more helpful during the pushing phase because they can facilitate effective pushing and help the baby descend into the birth canal. The left-side position is more about circulation and preventing hypotension.
C) Prevent supine hypertension:
Supine hypotension occurs when the pregnant woman lies flat on her back, which can compress the inferior vena cava and reduce blood return to the heart. This leads to a drop in blood pressure and can compromise both maternal and fetal circulation. The left-side position is recommended because it helps to prevent this compression and allows optimal blood flow to both the mother and fetus, improving oxygenation and circulation.
D) Prevent the client from falling out of bed:
While lying on the left side may make the woman feel more stable, the primary reason for this position is to prevent supine hypotension, not to prevent her from falling out of bed. The nurse would ensure safety by using appropriate bed rails and monitoring, but the primary concern is supporting optimal circulation, not preventing falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Flexion:
Flexion is a movement where the fetal head bends forward during labor, which allows the smallest diameter of the head to pass through the birth canal. It is an important part of the labor process but does not refer to the initial descent of the fetus into the pelvis. Flexion typically occurs once the fetus begins to descend into the pelvis.
B) Engagement:
Engagement refers to the initial descent of the fetal head into the pelvis and the passage of the largest part of the fetal head (the biparietal diameter) into the maternal pelvis. This occurs when the fetal head reaches zero station at the level of the ischial spines and is the first cardinal movement of labor. It marks the point at which the presenting part of the fetus enters the pelvic inlet and begins the process of descent.
C) Extension:
Extension is the movement of the fetal head as it exits the birth canal after engagement and descent. The head moves from a flexed position (chin to chest) to an extended position (chin moving away from the chest) as it passes through the birth canal. This movement occurs after engagement and is a part of the expulsion phase, not the initial descent.
D) Expulsion:
Expulsion is the final phase of labor, which occurs after the fetal head has been delivered. It involves the delivery of the rest of the body (shoulders, torso, and legs) following the birth of the head. This is the final cardinal movement, which takes place after engagement, descent, flexion, internal rotation, extension, and external rotation.
Correct Answer is B
Explanation
A) "There are specific pain management options that you need to use":
It’s important to respect the client's autonomy and work collaboratively to explore pain management options that align with their cultural values and medical safety. A more open, client-centered approach would be more beneficial.
B) "We will work with you to incorporate the practices that are safe for you and your fetus.":
This statement acknowledges the client's cultural preferences while ensuring that safety is the priority. The nurse is offering to collaborate with the client to explore pain management options that align with their values, within the scope of what is medically safe for both the mother and the fetus. It promotes a partnership approach, which is critical in maternity care.
C) "You will need to discuss this with the provider.":
While the provider may ultimately be involved in deciding specific pain management options, this statement dismisses the nurse's role in supporting the client’s cultural preferences. Nurses can play an active role in initiating and facilitating these conversations with clients and helping them express their preferences to the provider. It is not solely the provider's responsibility.
D) "It is better to use pain management options that have been researched.":
While evidence-based practices are important, this statement could be seen as dismissive of the client's cultural preferences. It fails to address the importance of individualized care and overlooks the possibility of integrating safe, culturally relevant pain management practices alongside researched methods. A balanced approach that respects both cultural values and medical safety is crucial.
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