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 D
Explanation
Choice D reason: A client who has preeclampsia and reports epigastric pain and unresolved headache should be reported to the RN immediately, as these are signs of severe preeclampsia and impending eclampsia, which can lead to seizures, coma, and death. The client may need anticonvulsant medication, magnesium sulfate infusion, and delivery of the fetus.
Choice A reason: A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful may have preterm labor, which should be monitored and treated accordingly. However, this is not as urgent as choice D, as the contractions may subside with hydration, rest, or tocolytic medication.
Choice B reason: A client who has preeclampsia has 2+ patellar reflexes and 2+ proteinuria may have mild preeclampsia, which should be managed with antihypertensive medication, bed rest, and fetal monitoring. However, this is not as urgent as choice D, as the reflexes and proteinuria are not indicative of severe preeclampsia or eclampsia.
Choice C reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors may have a common side effect of terbutaline, which is a beta-adrenergic agonist that relaxes uterine smooth muscle and inhibits contractions. However, this is not as urgent as choice D, as the tremors are usually transient and benign. The nurse should monitor the client's vital signs, blood glucose, and fetal heart rate.
Correct Answer is B
Explanation
Choice A reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice B reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines is correct, as this follows the correct order and measurement of cervical assessment. Cervical dilation, effacement, and station are recorded in that order to describe the progress of labor. Station refers to the relationship between the presenting part of the fetus and the maternal pelvis, measured by the level of the ischial spines. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
Choice C reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice D reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not match the documentation of station. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
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