A client who is primiparous at 40 weeks of gestation calls the labor and delivery unit to ask about coming in to be evaluated for labor. The client reports having contractions every 6 to 8 min, which feels slightly painful. Which of the following questions should the nurse ask the client next?
"Have you had any health concerns during your pregnancy?"
Do have a support person present?"
Have you noticed any fluid leaking from your vagina?"
When was your last prenatal visit?
The Correct Answer is C
A) "Have you had any health concerns during your pregnancy?"
While it's important to assess the client's overall health and pregnancy history, this question doesn't directly address the current concern of possible labor and does not immediately help assess the client's status for labor evaluation. The focus should be on signs of labor or complications at this point.
B) "Do you have a support person present?"
Although this is a helpful question to ask in preparation for labor, it doesn't provide the necessary information needed to assess whether the client is in labor. The priority at this stage is determining if the client is in labor or experiencing any complications, such as rupture of membranes.
C) "Have you noticed any fluid leaking from your vagina?"
This is the most important question to ask next. If the client has ruptured membranes (i.e., water breaking), it is important to assess the timing and nature of the fluid leakage, as it would indicate the need for immediate evaluation at the hospital. Rupture of membranes requires monitoring for infection and should prompt the client to come in for assessment regardless of the frequency or intensity of contractions.
D) "When was your last prenatal visit?"
While it is helpful to know when the client had their last prenatal visit, this question does not directly address the issue of possible labor. The priority is to determine if the client is in labor, whether their membranes have ruptured, or if there are any other complications such as bleeding or abnormal fetal movement. The question about fluid leakage is more immediate and relevant to their current condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Fetal heart monitoring:
Nurses are trained to monitor fetal heart rates, interpret patterns, and identify signs of distress, but this task is typically within the scope of a registered nurse's (RN) practice. It may not involve the critical decision-making or advanced skills associated with the highest level of licensure.
B) Taking specimens to the lab:
Taking specimens to the laboratory is a necessary but routine part of care. While it is important for ensuring proper diagnostic testing, it is a lower-level task and does not demonstrate the highest level of nursing practice. This task is often delegated or performed as part of standard nursing duties.
C) Performing vaginal delivery:
Performing a vaginal delivery is a high-level skill that typically requires advanced education, certification, and licensure beyond that of a registered nurse. This is usually performed by a midwife, obstetrician, or other healthcare providers with advanced training and certification. In many settings, a registered nurse may assist with vaginal deliveries but cannot independently perform them unless they have additional certifications (such as Certified Nurse Midwife).
D) Giving a client a bed bath:
While important for patient care and comfort, giving a client a bed bath is a basic nursing task that does not demonstrate working at the highest level of licensure. It is a fundamental nursing activity often carried out by nurses, nursing assistants, or other support staff. The act of providing a bed bath is part of the foundational skill set and does not require advanced knowledge or decision-making that would demonstrate the highest level of practice.
Correct Answer is ["A","B","D"]
Explanation
A) Change client position every 30 minutes:
Changing positions regularly during the second stage of labor can help facilitate fetal descent and improve the effectiveness of contractions. This strategy also helps relieve pressure on certain areas of the body, such as the perineum and lower back, promoting more effective pushing and reducing the need for assisted delivery. Frequent position changes can help the mother progress in labor without the need for tools or interventions.
B) Upright positions:
Upright positions, such as standing, squatting, or kneeling, can be beneficial in the second stage of labor. These positions allow gravity to assist in the descent of the baby, which can help avoid the need for forceps or vacuum extraction. Upright positions also tend to open up the pelvis and can result in more effective pushing, reducing the likelihood of an assisted vaginal delivery.
C) Supine positions:
Supine positions (lying on the back) are not recommended for avoiding an assisted vaginal birth. Lying on the back can hinder fetal descent and may also lead to increased pressure on the inferior vena cava, which can decrease blood flow and oxygen to the uterus. This position tends to slow down labor and may increase the need for interventions like forceps or vacuum extraction, making it less favorable for a spontaneous vaginal delivery.
D) Lateral positions:
Lateral positions (lying on one side) can also help in the second stage of labor. This position can improve uterine blood flow, relieve pressure on the perineum, and provide more room for the baby to descend. It is a good alternative to supine positions and can aid in achieving a vaginal birth without assistance.
E) Delayed pushing:
Delayed pushing can be helpful for some clients, especially if they are not fully dilated or if they need time to rest. However, delayed pushing is not directly related to preventing an assisted vaginal birth. In fact, if the mother waits too long to push or doesn't push effectively, it could potentially lead to more complications or require assisted interventions. The key is ensuring that pushing is done effectively and at the right time in the second stage, rather than delaying it unnecessarily.
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