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 A
Explanation
Choice A rationale :
Prepare for cesarean birth. The nurse should consider preparing for a cesarean birth as the client is at 39 weeks of gestation and has heavy vaginal bleeding. Heavy vaginal bleeding during pregnancy could indicate an emergency situation such as placental abruption or placenta previa, both of which can be life-threatening for the mother and the baby. In such cases, an emergency cesarean birth might be necessary to ensure the safety of both the client and the baby. Promptly preparing for the procedure will help expedite the process and prevent any delays in providing necessary medical care.
Choice B rationale
Initiate an IV infusion of magnesium sulfate. Magnesium sulfate is not indicated in this situation. Magnesium sulfate is commonly used in obstetrics, particularly in the management of preeclampsia and eclampsia to prevent seizures. However, the client's heavy vaginal bleeding suggests a different issue and magnesium sulfate would not address the underlying cause. Instead, the focus should be on identifying and managing the cause of the bleeding to ensure the best outcome for the client and the baby.
Choice C rationale
Administer antibiotics. Administering antibiotics is not the priority action in this scenario. Heavy vaginal bleeding in a pregnant client requires immediate attention to assess the cause and determine the appropriate course of action. While antibiotics may be necessary in some situations, they are not the first-line treatment for heavy vaginal bleeding during pregnancy. The nurse should focus on providing prompt and appropriate care to address the client's immediate needs.
Choice D rationale
Request the RN to perform a cervical examination. Performing a cervical examination may provide valuable information about the cause of the heavy vaginal bleeding. It can help determine if the bleeding is related to cervical changes, such as cervical dilation or effacement. The findings from the cervical examination, along with other assessments, will aid in making the most appropriate decisions regarding the client's care. However, it is not the only action that the nurse should take. In this critical situation, the nurse must prioritize immediate interventions to ensure the safety and well-being of the client and the baby.
Correct Answer is A
Explanation
Choice A rationale:
Visual disturbances should be reported to the provider because the client is experiencing headaches, blurred vision, and dizziness, which can be signs of preeclampsia. Preeclampsia is a serious condition that can develop during pregnancy and is characterized by high blood pressure and damage to organs like the liver and kidneys. Visual disturbances may indicate neurological involvement and can pose a risk to both the client and the fetus.
Choice B rationale:
Blood pressure should be reported to the provider due to the client's symptoms and medical history. The client's weight gain, swelling of feet and fingers, and 2+ pitting edema suggest fluid retention, which can be associated with preeclampsia. High blood pressure is a key diagnostic criterion for preeclampsia, and the nurse must monitor it closely to assess the severity of the condition and the potential risk to both the client and the fetus.
Choice C rationale:
Respirations do not appear to be a significant concern based on the information provided. While respiratory status is important to monitor during pregnancy, there are no indications in the scenario to suggest respiratory distress or abnormalities that require immediate reporting to the provider.
Choice D rationale:
Deep tendon reflexes are mentioned in the client's medical history but do not show any immediate signs of concern. Absent clonus and 3+ deep tendon reflexes are within the normal range and not typically alarming during pregnancy. However, the nurse should continue to monitor these reflexes during subsequent visits.
Choice E rationale:
Weight gain is mentioned in the medical history but is not currently a critical finding to report. A 6 lb weight gain over 2 weeks may be considered appropriate for a pregnant client at 32 weeks of gestation, but it should be assessed in conjunction with other symptoms for a comprehensive evaluation.
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