A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make to the client?

You should try to pant as the delivery proceeds

You should try to perform slow-paced breathing

You should take a deep cleansing breath and breathe naturally

You should go ahead and push to assist the delivery

Answer and Explanation

The Correct Answer is A

a. Panting helps to control the urge to push and can slow down the delivery, which is important to prevent rapid delivery that could cause injury to both the mother and the baby. It allows the nurse or healthcare provider to better manage the delivery process.

b. Slow-paced breathing is often used during early labor to help manage pain and anxiety. However, when the baby’s head is crowning, panting is more effective in controlling the urge to push and slowing down the delivery process.

c. While deep cleansing breaths can be helpful during contractions to manage pain and focus, they are not as effective as panting in controlling the urge to push during the crowning phase.

d. While it might seem natural to encourage pushing when the baby’s head is crowning, it’s important to control the delivery to prevent rapid birth, which can cause injury to both the mother and the baby. Encouraging the mother to pant helps slow down the process, allowing for a more controlled and safer delivery.

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Correct Answer is A

Explanation

The correct answer is A. Blood pressure 80/56 mm Hg.

A. A blood pressure of 80/56 mm Hg is the priority finding. Opioid analgesia can cause hypotension, and addressing low blood pressure is crucial to prevent maternal and fetal complications. The nurse should notify the healthcare provider promptly and implement interventions to improve blood pressure.

B. Profuse itching is a common side effect of opioids and is generally not considered a priority unless it becomes severe or is accompanied by other concerning symptoms.

C. A temperature of 38.2°C (100.8°F) may indicate a fever, but addressing hypotension takes precedence. Elevated temperature can be further assessed but is not the priority in this scenario.

D. The client reporting weakness of the lower extremities is a concerning symptom, but the priority is to address hypotension first, as it could be related to opioid-induced hypotension.

A. "You will need to drink the glucose solution 2 hours prior to the test." B. "Limit your carbohydrate intake for 3 days prior to the test." C. "A blood glucose of 130 to 140 is considered a positive screening result. D. "You will need to fast for 12 hours prior to the test

Correct Answer is C

Explanation

Choice A Reason:

Drinking the glucose solution 2 hours prior to the test is not standard for a 1-hour GTT. Instead, the glucose solution is usually consumed within a short timeframe, such as 5 minutes, and the blood is drawn 1 hour afterward.

Choice B Reason:

Limiting carbohydrate intake for 3 days prior to the test is not a requirement for a 1-hour GTT. However, it may be advised for a longer fasting period or a different type of glucose tolerance test.

Choice C Reason:

C. “A blood glucose of 130 to 140 is considered a positive screening result.”

In the 1-hour glucose tolerance test during pregnancy, a blood glucose level of135 mg/dL or higheris considered a positive screening result. If this threshold is met, further testing (such as the 3-hour glucose tolerance test) is recommended to confirm or rule out gestational diabetes.

Choice D Reason:

Fasting for 12 hours prior to the test is inappropriate. For a 1-hour GTT, the client is not typically required to fast.

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A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

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