A nurse in the emergency department is admitting a client who is experiencing an especially rapid labor (precipitous labor). She is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head crowning. The client tells the nurse she feels a strong urge to push. Which of the following instructions should the nurse make to help the mother have a more controlled birth?
"You should take a deep, cleansing breath and breathe naturally."
"You should go ahead and push as hard as you can to assist the delivery."
"You should try to blow or pant as the baby is being born to help avoid a toorapid birth."
"You should try to perform slowpaced breathing patterns."
The Correct Answer is C
A: Taking deep, cleansing breaths and breathing naturally is not the appropriate technique during the crowning phase of labor, as it can increase the risk of rapid birth and potential perineal trauma.
C: During a precipitous labor with the baby's head crowning, the nurse should encourage the mother to perform blowing or panting breaths during contractions. This technique helps to slow down the delivery process and allows the perineum to stretch gradually, reducing the risk of tearing or other trauma.
B: In the case of precipitous labor, actively pushing as hard as possible can increase the risk of rapid birth and potential complications for both the mother and the baby.
D: Slowpaced breathing patterns are not recommended during the crowning phase of labor, as they may not effectively control the birth process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A surge of energy: Some women experience a sudden burst of energy, often referred to as a "nesting" instinct, shortly before the onset of labor.
B. Urinary retention: Urinary frequency and urgency are more common before labor, not urinary retention.
C. Decreased vaginal discharge: Before labor, there might be an increase in vaginal discharge, often thick and pinkish, known as the "bloody show."
D. Weight gain of 0.5 to 1.5 kg: Weight gain is not typically associated with the onset of labor.
Correct Answer is C
Explanation
Choice A: A weight gain of about 1 pound per week is a general guideline for women with normal BMI. However, for a client with a BMI of 26.5, the recommended weight gain during pregnancy may differ.
Choice B: Gaining 11 to 20 pounds may not be sufficient for a client with a BMI of 26.5, as the recommended weight gain is slightly higher for women with a higher prepregnancy BMI.
Choice C: For a client with a BMI of 26.5, the recommended weight gain during pregnancy is approximately 15 to 25 pounds. This range is specific to women with a BMI in the overweight category.
Choice D: Gaining 25 to 35 pounds is recommended for clients with a lower BMI range (normal BMI). For a client with a BMI of 26.5, this amount of weight gain may be excessive.
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