A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take?
Check the client's temperature every 4 hr.
Remind the client to bear down with each contraction.
Maintain the client in the lithotomy position.
Encourage the client to empty the bladder every 2 hr.
The Correct Answer is D
Choice A reason: Check the client's temperature every 4 hr is incorrect, as this action is not frequent enough for a client who had an amniotomy. The nurse should check the client's temperature every 2 hr after an amniotomy, as there is an increased risk of infection due to the rupture of membranes. The nurse should also monitor for signs of chorioamnionitis, such as foul-smelling amniotic fluid, maternal tachycardia, or fetal tachycardia.
Choice B reason: Remind the client to bear down with each contraction is incorrect, as this action is not appropriate for a client who is in the active phase of the first stage of labor. The nurse should instruct the client to avoid bearing down or pushing until they are in the second stage of labor, when the cervix is fully dilated and effaced. Bearing down too early can cause cervical edema, lacerations, or exhaustion.
Choice C reason: Maintain the client in the lithotomy position is incorrect, as this action is not optimal for a client who is in the active phase of the first stage of labor. The lithotomy position is a supine position with the legs elevated and abducted, which can reduce blood flow to the uterus and placenta, increase perineal edema, and limit pelvic outlet diameter. The nurse should encourage the client to change positions frequently and use upright or lateral positions that can enhance uterine contractility, fetal descent, and maternal comfort.
Choice D reason: Encourage the client to empty the bladder every 2 hr is correct, as this action can promote labor progress and prevent bladder distension and infection. The nurse should assist the client to void every 2 hr after an amniotomy, as there may be decreased sensation of bladder fullness due to pressure from the fetal head. A full bladder can interfere with uterine contractions, fetal descent, and cervical dilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Checking the consistency of the client's uterine fundus is the first action the nurse should take, as it can indicate the cause of excessive bleeding. A boggy or soft fundus indicates uterine atony, which is the most common cause of postpartum hemorrhage. The nurse should massage the fundus until it becomes firm and contracted.
Choice B reason:
Having the client use the bedpan to urinate is an important action, as a full bladder can displace the uterus and prevent it from contracting properly. However, this is not the first action the nurse should take, as it does not address the immediate source of bleeding.
Choice C reason:
Increasing the client's fluid intake is an important action, as it can help replace fluid loss and prevent hypovolemia and shock. However, this is not the first action the nurse should take, as it does not stop the bleeding.
Choice D reason:
Preparing to administer oxytocic medication is an important action, as it can stimulate uterine contractions and reduce bleeding. However, this is not the first action the nurse should take, as it requires a provider's prescription and may not be necessary if fundal massage is effective.
Correct Answer is A
Explanation
Choice A reason:
Fetal position is persistent occiput posterior is correct, as this position can cause difficult, prolonged labor and severe backache. The occiput posterior position means that the back of the fetal head is facing the maternal sacrum, which can result in poor alignment and descent, increased pressure on the maternal sacrum and nerves, and increased risk of perineal trauma. The nurse should encourage the client to change positions frequently, use pelvic rocking exercises, apply counterpressure to the sacrum, and administer analgesics as needed.
Choice B reason:
Fetal attitude is in general flexion is incorrect, as this attitude can facilitate normal labor and delivery. The fetal attitude refers to the degree of flexion or extension of the fetal head and limbs in relation to the fetal trunk. General flexion means that the fetal head is flexed on the chest, the arms are crossed over the chest, and the legs are flexed at the knees. This attitude allows the smallest diameter of the fetal head to pass through the birth canal.
Choice C reason:
Fetal lie is longitudinal is incorrect, as this lie can facilitate normal labor and delivery. The fetal lie refers to the relationship between the long axis of the fetus and the long axis of the mother. Longitudinal lie means that both axes are parallel, which allows for either a vertex (head-first) or a breech (butocks-first) presentation.
Choice D reason:
Maternal pelvis is gynecoid is incorrect, as this pelvis can facilitate normal labor and delivery. The maternal pelvis refers to the shape and size of the bony pelvis that affects the passage of the fetus. Gynecoid pelvis is the most common and favorable type for vaginal birth, as it has a rounded inlet, a wide pubic arch, and adequate outlet dimensions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today