A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?
Fetal position is persistent occiput posterior.
Fetal attitude is in general flexion.
Fetal lie is longitudinal.
Maternal pelvis is gynecoid.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Massage the client's fundus is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Saturating a perineal pad in 10 min indicates excessive bleeding and possible postpartum hemorrhage, which can compromise the client's airway, breathing, and circulation. Massaging the fundus can stimulate uterine contraction and reduce blood loss.
Choice B reason: Check the client's blood pressure is incorrect, as this is not the first action the nurse should take, although it is important to monitor for signs of shock. Checking the blood pressure does not address the cause of bleeding or prevent further blood loss.
Choice C reason: Administer oxytocin is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Administering oxytocin requires a provider's order and may have adverse effects such as nausea,
vomiting, headache, or water intoxication. The nurse should first atempt to control bleeding by massaging the fundus and then administer oxytocin as ordered.
Choice D reason: Observe for pooling of blood under the butocks is incorrect, as this is not the first action the nurse should take, although it can help estimate blood loss. Observing for pooling of blood does not address the cause of bleeding or prevent further blood loss. The nurse should first atempt to control bleeding by massaging the fundus and then assess for other signs of hemorrhage.
Correct Answer is B
Explanation
Choice B reason:
Auscultating the client's abdomen is the first action the nurse should take, as it can assess the return of bowel function after surgery. The nurse should listen for bowel sounds in all four quadrants, and note their frequency and quality.
Offering clear liquids is an important action, as it can provide hydration and nutrition for the client. However, this is not the first action the nurse should take, as it may cause nausea and vomiting if the client's bowel function has not returned.
Choice C reason:
Checking the client's chart for a diet prescription is an important action, as it can ensure that the client follows the provider's orders and does not consume anything contraindicated. However, this is not the first action the nurse should take, as it does not address the client's hunger or bowel function.
Choice D reason:
Giving the client soda crackers is an important action, as it can provide a bland and easily digestible food for the client. However, this is not the first action the nurse should take, as it may be too solid for the client's stomach if her bowel function has not returned.
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