A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client?
"Take a deep, cleansing breath before and after each contraction.".
"Hold your breath and push while I count to ten.".
"You should push continuously throughout the entire contraction.".
"I will let you know when you should push according to your contractions.".
The Correct Answer is D
Choice A rationale:
The nurse should not advise the client to take deep, cleansing breaths before and after each contraction because it can interfere with the natural urge to push and may not be effective in helping with the labor process. When a client feels the urge to push, it is essential to work with their body's natural instincts.
Choice B rationale:
Instructing the client to hold their breath and push while counting to ten is not recommended. This Valsalva manoeuvre can cause a sudden increase in intra-abdominal pressure, which may reduce blood flow to the heart and brain and may be harmful to both the client and the baby. It's crucial to promote safe pushing techniques during labor.
Choice C rationale:
The instruction to push continuously throughout the entire contraction is also not ideal. Pushing continuously can lead to exhaustion and decrease the effectiveness of each push. It's essential to guide the client on when and how to push effectively to prevent unnecessary fatigue.
Choice D rationale:
The correct instruction is to let the client know when to push according to their contractions. The urge to push is a natural reflex that signifies the baby's descent into the birth canal. The nurse should encourage the client to listen to their body and push when they feel the urge during the contractions. This approach optimizes the client's efforts and conserves their energy for delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Place the client in a knee-chest or Trendelenburg position.
Choice A rationale:
Preparing the client for an emergency cesarean birth is important, but it is not the immediate first action. The priority is to relieve pressure on the umbilical cord to prevent fetal hypoxia.
Choice B rationale:
Explaining to the client what is happening is important for communication and reassurance, but it is not the immediate first action. Immediate physical intervention is required to prevent harm to the fetus.
Choice C rationale:
Covering the cord with a sterile, moist saline dressing is a necessary step to prevent the cord from drying out and to reduce infection risk, but it should be done after repositioning the client to relieve pressure on the cord.
Choice D rationale:
Placing the client in a knee-chest or Trendelenburg position helps to relieve pressure on the umbilical cord, which is crucial to maintain fetal oxygenation. This is the immediate first action to take in this emergency situation.
Correct Answer is D
Explanation
The cervix is dilated 3 cm: This indicates the width of the cervical opening, which is 3 cm wide.
It is effaced 30%: This means the cervix has effaced or thinned out by 30%, indicating how much the cervix has shortened and thinned in preparation for labor.
The presenting part is 1 cm above the ischial spines (indicated by the negative number, -1): This measurement shows the position of the baby's head in relation to the ischial spines of the pelvis. In this case, the baby's head is 1 cm above the ischial spines.
Option A ("The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines."): This option incorrectly interprets the baby's position as being 1 cm below the ischial spines, which is not the case. The negative sign (-1) in the documentation indicates that the presenting part is 1 cm above the ischial spines.
Option B ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines."): This option switches the interpretation of dilation and effacement. In the original documentation, the dilation is given as 3 cm, while effacement is 30%. This option incorrectly states that effacement is 3 cm and dilation is 30%. Additionally, it correctly identifies the presenting part's position.
Option C ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines."): This option correctly interprets effacement and dilation but incorrectly states that the presenting part is 1 cm below the ischial spines. The original documentation indicates that the presenting part is 1 cm above the ischial spines, as denoted by the negative sign (-1).
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