The nurse is caring for a laboring woman, G3 P2, who was examined 15 minutes ago.
Her cervix was 8 cm dilated and 90% effaced.
She now states she is feeling strong pressure in her rectum and wants to move her bowels.
Which of the following action should the nurse perform first?
Perform a vaginal exam.
Encourage the patient to push.
Notify the MD.
Offer the patient the bedpan.
The Correct Answer is A
Choice A rationale
Strong rectal pressure indicates advanced labor and potential imminent delivery, requiring immediate assessment of cervical dilation to ensure appropriate intervention and prevent complications.
Choice B rationale
Encouraging the patient to push without confirming cervical dilation could lead to cervical trauma or delivery complications if dilation is not complete, making this action inappropriate.
Choice C rationale
Notifying the MD without first assessing cervical dilation may cause unnecessary delay in intervention, potentially leading to complications during labor and delivery if the patient is fully dilated.
Choice D rationale
Offering the patient the bedpan when she feels strong rectal pressure can increase the risk of delivering the baby in an inappropriate setting, as the rectal pressure suggests imminent birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Pitocin is used for augmentation of labor to increase uterine contractions' frequency and strength, enhancing labor progression in cases where labor is slow or stalled.
Choice B rationale
Pitocin does not increase prolactin receptor sites; instead, it focuses on enhancing uterine contractions during labor and addressing postpartum hemorrhage.
Choice C rationale
Pitocin is used for induction of labor to stimulate uterine contractions and initiate labor in women who need medical intervention for various reasons.
Choice D rationale
Pitocin helps decrease bleeding after delivery by promoting uterine contractions, which aid in reducing postpartum hemorrhage and expelling the placenta.
Correct Answer is C
Explanation
Choice A rationale
Limited perception of bladder fullness can occur with epidural anesthesia, but it is not the most common or harmful complication. Patients should be monitored for urinary retention.
Choice B rationale
Severe afterbirth headache, or post-dural puncture headache, can result from epidural complications, but it is less common than hypotension.
Choice C rationale
Hypotension is the most common and potentially harmful complication of epidural anesthesia. It occurs due to sympathetic nerve blockade, leading to vasodilation and decreased cardiac output. Normal blood pressure ranges: systolic 90-120 mmHg, diastolic 60-80 mmHg.
Choice D rationale
Increased respiratory rate is not a common complication of epidural anesthesia. It is more likely related to anxiety or other factors and should be monitored accordingly.
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