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 C
Explanation
The correct answer is choice C. Assist the client to breathe into a paper bag.
Choice A rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate. This could exacerbate hyperventilation, leading to further lightheadedness and tingling.
Choice B rationale:
Administering oxygen via nasal cannula is not necessary in this situation. The symptoms are due to hyperventilation, not a lack of oxygen.
Choice C rationale:
Assisting the client to breathe into a paper bag helps to rebreathe carbon dioxide, which can correct the respiratory alkalosis caused by hyperventilation. This will alleviate the symptoms of lightheadedness and tingling.
Choice D rationale:
Having the client tuck her chin to her chest is not a recognized intervention for hyperventilation. It would not address the underlying issue of respiratory alkalosis.
Correct Answer is C
Explanation
Choice A rationale :
Scrambled eggs. Taking ferrous sulfate with scrambled eggs is not the optimal choice because eggs contain phytates, which can bind to iron and reduce its absorption. Therefore, it may hinder the effectiveness of the iron supplement, and the client may not receive the full benefit of the medication.
Choice B rationale
A high-fibre meal. While fiber is generally beneficial for digestion and overall health, it is not the best choice to take with ferrous sulfate. Fiber can also interfere with iron absorption in the same way as phytates, potentially reducing the medication's effectiveness.
Choice C rationale
Orange juice. The nurse should instruct the client to take the ferrous sulfate with orange juice. Orange juice is an excellent choice because it is rich in vitamin C. Vitamin C enhances the absorption of non-heme iron (the type of iron found in plant-based sources like ferrous sulfate). By taking the medication with orange juice, the client can maximize the absorption of iron and improve the treatment of iron-deficiency anaemia.
Choice D rationale
Milk. Consuming ferrous sulfate with milk is not advisable. Calcium, present in milk, can inhibit the absorption of iron. Therefore, taking the medication with milk might reduce the efficacy of the iron supplement and not provide the desired therapeutic effect.
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