A nurse is assisting with the care of a client who is multigravida 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 the bladder
Assist the client to a comfortable position
Assess the perineum for signs of crowning
Have the client pant during the next few contractions
The Correct Answer is D
A. Help the client to the bathroom to empty the bladder: It is unsafe to ambulate a client in active labor who feels the urge to push; crowning must first be ruled out.
B. Assist the client to a comfortable position: Comfort is important, but immediate assessment for crowning takes priority to prepare for delivery.
C. Assess the perineum for signs of crowning: While this is an important assessment, the immediate action to take when the client feels the urge to push is to instruct her to pant to prevent premature pushing.
D. Have the client pant during the next few contractions: Panting helps the patient avoid pushing before full dilation is achieved, reducing the risk of complications such as cervical lacerations or fetal distress. This technique helps manage the urge to push until the cervix is fully dilated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An external fetal monitor will be used to monitor the FHR: Nonstress tests (NST) monitor the fetal heart rate (FHR) in response to fetal movements using external monitors.
B. The client will receive an ultrasound prior to the test: An ultrasound is not part of the standard procedure for an NST.
C. An IV will be initiated prior to the test: An IV is unnecessary; the test is noninvasive.
D. The client will be asked to stimulate her nipples for 5 min during the test: Nipple stimulation is part of a contraction stress test, not an NST.
Correct Answer is A
Explanation
A. Cramping and backache with light spotting: These are classic signs of a threatened abortion, where the pregnancy is at risk but not yet lost.
B. Cervix is dilated: A dilated cervix indicates an inevitable or incomplete abortion, not a threatened one.
C. Passage of all products of conception has occurred: This describes a complete abortion.
D. Fetus died in utero but is not expelled: This describes a missed abortion, not a threatened abortion.
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