With regard to their role in the personal hygiene of the expectant mother, maternity nurses should be aware that:
Tub bathing is permitted even in late pregnancy unless membranes have ruptured.
The perineum should be wiped from back to front.
Expectant mothers should use specially treated soap to cleanse the nipples.
Bubble bath and bath oils are permissible because they add an extra soothing and cleansing action to the bath.
The Correct Answer is A
Choice A rationale
Tub bathing is generally considered safe throughout pregnancy, including late gestation, as long as the woman is comfortable getting in and out of the tub and the water is not excessively hot. However, tub bathing should be avoided after the rupture of membranes (amniotic sac) to minimize the risk of ascending bacterial infection into the uterus.
Choice B rationale
Proper perineal hygiene involves wiping from front to back (urethra to anus). This technique prevents the transfer of fecal bacteria, such as Escherichia coli, from the anal area to the vaginal or urethral openings, significantly reducing the risk of developing a urinary tract or vaginal infection.
Choice C rationale
Cleansing the nipples during pregnancy is typically done with plain water and is part of the regular daily shower or bath routine. The use of specially treated soaps or harsh chemicals on the nipples should be avoided as they can remove protective oils and increase the dryness or irritation of the skin.
Choice D rationale
While bath time can be relaxing, expectant mothers should be advised to avoid using bubble baths, bath oils, or heavily scented soaps. These substances can sometimes irritate the sensitive vulvar and vaginal tissues, potentially leading to inflammation, itching, or even predisposing to a vaginal infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A fundal height 3 cm below the umbilicus at 20 weeks of gestation is not considered higher than normal. At approximately 20 weeks, the fundus should be reliably palpable right at the level of the umbilicus, which serves as a clinical landmark. A fundus that is higher than the umbilicus at this point might suggest an error in dating, multiple gestation, or polyhydramnios, but the described finding is the opposite.
Choice B rationale
A fundal height 3 cm below the umbilicus at 20 weeks is not typically a sign of impending complications, but it does suggest the uterus is measuring smaller than expected for the gestational age. Clinical assessment of fundal height is often used to screen for intrauterine growth restriction (IUGR) or oligohydramnios, which would require further diagnostic investigation like an ultrasound, but this specific finding is low, not high.
Choice C rationale
The fundus is generally expected to be palpable at the umbilicus (approximately 20 cm from the symphysis pubis) when the client is at 20 weeks of gestation. A finding of 3 cm below the umbilicus is significantly lower than this established norm. Fundal height measurement is a simple, quick method to estimate gestational age and assess fetal growth.
Choice D rationale
At 20 weeks of gestation, the uterine fundus should be at the level of the umbilicus. If the fundus is palpated 3 cm below the umbilicus, it is considered lower than expected for gestational age, suggesting that the uterus is smaller than anticipated. This finding warrants further investigation, such as ultrasound, to confirm the gestational age and rule out conditions like intrauterine growth restriction or oligohydramnios.
Correct Answer is ["A","C"]
Explanation
Choice A rationale
Instructing the mother to push with contractions and rest in between is the correct approach to conserve her energy and maximize the effectiveness of pushing efforts during the second stage of labor. This technique, often called open-glottis pushing, allows for physiological rest and prevents maternal exhaustion, optimizing oxygen exchange.
Choice B rationale
Administering prophylactic oxygen to the mother during pushing is not routinely recommended and has no established benefit for maternal strength or fetal well-being in an otherwise healthy labor. Oxygen is administered only if the mother shows signs of distress or if the fetal heart rate tracing indicates non-reassuring changes.
Choice C rationale
Assessing the fetal heart rate (FHR) every 5 to 15 minutes is the standard of care for a low-risk woman during the second stage of labor. This frequent assessment is critical for monitoring the fetus's response to the stress of uterine contractions and pushing, allowing for timely intervention if signs of distress emerge.
Choice D rationale
Performing a sterile vaginal examination (SVE) to check for dilation in a woman with a strong urge to push is generally unnecessary once the woman is in the second stage of labor, indicating full dilation. An SVE is performed to assess fetal station, position, and to confirm complete dilation, not as a primary action when pushing has already commenced.
Choice E rationale
Notifying the provider that the woman is having the urge to push may not be necessary if the provider is already aware of the labor progression and is present or immediately available. The primary actions are the direct care and support of the laboring woman, and notification depends on the provider's typical practice and proximity.
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