The nurse who performs vaginal examinations to assess a woman's progress in labor should:
Wear two clean gloves for each examination.
Perform the examination with the woman in the supine position.
Discuss the findings with the woman and her partner.
Perform an examination at least once every hour during the active phase of labor.
The Correct Answer is C
Choice A rationale
Vaginal examinations require aseptic technique to prevent ascending infection, especially after membrane rupture. The nurse should use a single, sterile glove on the examining hand for each examination, not two clean gloves, as the clean technique is insufficient for this invasive procedure.
Choice B rationale
The ideal position for a vaginal examination during labor is the dorsal recumbent position, with the woman lying on her back with knees bent and hips flexed, allowing for optimal access and comfort. The supine position without hip flexion may be less comfortable and limit access, though it is often used.
Choice C rationale
Open communication is a key component of patient-centered care during labor. Discussing findings, such as cervical dilation, effacement, and fetal station, with the woman and her partner helps them understand the progress of labor, decreases anxiety, and promotes participation in the birthing process.
Choice D rationale
While regular assessment is necessary, performing a vaginal examination at least once every hour during the active phase of labor is excessive and increases the risk of intrauterine infection. The exam should be performed judiciously, typically every two to four hours, or when clinically indicated (e.g., strong urge to push, suspicion of a complication).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Continued bloody show refers to the mucous plug mixed with a small amount of blood, which is a normal finding during labor as the cervix softens, effaces, and dilates. While the amount of bloody show is monitored, it is not the most immediate or critical concern compared to a pathway for bacterial ascent, especially in a GBS-positive client.
Choice B rationale
Cervical dilation of 4 cm indicates the client is in the active phase of the first stage of labor. Although the rate of dilation is important, a GBS-positive client at 4 cm is generally expected to progress, and this finding does not represent the highest risk compared to potential exposure from membrane rupture.
Choice C rationale
Contractions every 4 minutes indicate effective uterine activity for progression of labor, which is an expected physiological process. Monitoring contraction frequency and intensity is standard, but contractions themselves do not pose the greatest risk factor for a GBS-positive client compared to compromised integrity of the amniotic barrier.
Choice D rationale
Spontaneous rupture of membranes (SROM) 3 hours ago in a GBS-positive client significantly increases the risk of ascending infection, potentially leading to chorioamnionitis in the mother and neonatal sepsis. The GBS organism can colonize the birth canal, and once the barrier is broken for an extended period, the risk becomes acute, requiring prompt antibiotic prophylaxis.
Correct Answer is C
Explanation
Choice A rationale
Administering a narcotic analgesic may provide pain relief, but the woman's immediate need is for coping strategies and techniques to manage the present overwhelming sensation of pain and anxiety; teaching breathing first addresses the immediate crisis of her uncontrolled response to contractions.
Choice B rationale
Offering false reassurance that labor will be over soon is unhelpful and undermines trust, as the woman is in the active phase of labor (3 cm dilated), which can last many more hours, and this statement does not provide her with any practical coping mechanisms for her current distress.
Choice C rationale
Assisting the patient with simple breathing and relaxation instructions is the most important initial nursing action because it provides her with immediate, practical coping tools to decrease her pain perception, reduce anxiety, conserve energy, and regain a sense of control over her intense contractions.
Choice D rationale
Notifying the healthcare provider is important for updating them on labor progress and discussing pain management options like an epidural, but it is not the most immediate priority; the nurse must first intervene to help the patient manage her unmanaged pain and distress effectively using non-pharmacological methods.
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