A nurse is assisting with the care of a client who is multigravid and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriate nursing response?
Help the client to the bathroom to empty her bladder.
Assist the client into a comfortable position.
Have the client pant during the next few contractions.
Assess the perineum for signs of crowning.
The Correct Answer is C
Choice A rationale:
Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labour, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.
Choice B rationale:
Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.
Choice C rationale:
Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labour has commenced. Panting is not necessary at this point.
Choice D rationale:
The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Dysuria - Dysuria refers to painful or difficult urination. In a client with a urinary tract infection (UTI), this symptom is commonly present. The rationale behind this finding is that the infection irritates the urinary tract, causing discomfort and pain during urination. The client may experience a burning sensation or pressure while passing urine.
Choice D rationale
Hematuria - Hematuria refers to the presence of blood in the urine. In the case of a UTI, inflammation of the urinary tract can lead to tiny blood vessels rupturing, resulting in blood in the urine. This can cause the urine to appear pink, red, or brownish.
Choice E rationale:
Urinary frequency - Urinary frequency is another common symptom of a UTI. The infection can irritate the bladder lining, leading to an increased urge to urinate even when the bladder is not full. The client may feel the need to urinate frequently throughout the day and night.
Choice B rationale
Dependent edema - Dependent edema is not typically associated with a urinary tract infection. Edema is the accumulation of fluid in tissues, often causing swelling in the lower extremities due to gravity (dependent). This symptom is more commonly related to issues such as heart, kidney, or liver problems.
Choice C rationale
Polyuria - Polyuria refers to excessive urination, usually producing abnormally large volumes of urine. While frequent urination is a symptom of a UTI, polyuria, in this context, is not accurate. UTIs tend to cause frequent but smaller volumes of urine due to the irritation and inflammation of the bladder.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should recommend the client to increase cellulose and fluid in the diet. Cellulose is a type of fiber found in fruits, vegetables, and whole grains. Increasing fiber intake can help alleviate constipation by adding bulk to the stool and promoting regular bowel movements. Additionally, the recommendation to increase fluid intake complements the effect of fiber, as it softens the stool, making it easier to pass through the intestines. This combination of increased cellulose and fluid intake is a safe and natural way to address constipation during pregnancy without the need for medication or invasive interventions.
Choice B rationale:
Regular use of glycerine suppositories is not the best recommendation for pregnant clients experiencing constipation. Suppositories are inserted into the rectum to stimulate bowel movements and should only be used sparingly when other methods have failed. Pregnant individuals may have increased sensitivity, and it's essential to avoid unnecessary procedures or potential discomfort.
Choice C rationale:
Regular use of a laxative is also not the most suitable recommendation for a pregnant client with constipation. While laxatives can provide relief, they may lead to dependency and might have adverse effects on the developing fetus. It is best to explore safer and more natural methods before resorting to laxative use during pregnancy.
Choice D rationale:
Maintenance of good posture is essential during pregnancy for various rationales, but it is not a specific solution for constipation. While maintaining good posture can help alleviate back pain and other discomforts, it does not directly address the issue of constipation.
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