A nurse is caring for a client following an amniotomy, who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Encourage the client to empty her bladder every 2 hr.

Remind the client to bear down with each contraction.

Maintain the client in the lithotomy position.

Perform vaginal examinations frequently.

Answer and Explanation

The Correct Answer is A

A. Encourage the client to empty her bladder every 2 hr.: This is the correct choice. A full bladder can impede the descent of the fetus and can increase the client’s discomfort. Therefore, it’s important to encourage the client to empty her bladder regularly.
B. Remind the client to bear down with each contraction: This is not recommended during the active phase of the first stage of labor. The client should be instructed to bear down only during the second stage of labor when the cervix is fully dilated.
C. Maintain the client in the lithotomy position: This is not necessary during the active phase of the first stage of labor. The lithotomy position is typically used during the second stage of labor for the actual delivery of the baby. During the first stage, the client should be encouraged to find a comfortable position.
D. Perform vaginal examinations frequently: This is not recommended. Frequent vaginal examinations increase the risk of introducing infection. Vaginal examinations should be performed only when necessary to assess the progress of labor.

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Correct Answer is C

Explanation

Answer: (C) 4-0-1-2-2

Rationale:

A) 2-0-0-2-0: This option is incorrect because it does not accurately represent the client's pregnancy history. The GTPAL system includes:

G: Total number of pregnancies
T: Number of term deliveries (after 37 weeks)
P: Number of preterm deliveries (between 20 and 37 weeks)
A: Number of pregnancies ending in spontaneous or elective abortion (before 20 weeks)
L: Number of living children

For this client:

G: 4 (one current pregnancy, one abortion, and twins plus one more spontaneous abortion)
T: 0 (no deliveries at term)
P: 2 (twins born at 36 weeks and another preterm delivery)
A: 1 (one spontaneous abortion at 15 weeks)
L: 2 (living children from the twins)

B) 3-0-2-0-2: This option is incorrect because it does not account for the total number of pregnancies or the number of pregnancies ending in abortion accurately.

C) 4-0-1-2-2: This option is correct because it accurately represents the client's pregnancy history:

G (Gravida): 4 (including the current pregnancy and all past pregnancies)
T (Term deliveries): 0 (no deliveries at term)
P (Preterm deliveries): 2 (twins at 36 weeks and another preterm delivery)
A (Abortions): 1 (spontaneous abortion at 15 weeks)
L (Living children): 2 (twins)

D) 4-2-0-2-2: This option is incorrect because it misrepresents the number of term and preterm deliveries and does not account for the spontaneous abortion correctly.

A. Anaphylactoid syndrome of pregnancy B. Puerperal infection C. Preeclampsia D. Disseminated intravascular coagulation

Correct Answer is D

Explanation

A. Anaphylactoid syndrome of pregnancy: This is a rare but serious complication of pregnancy, typically associated with amniotic fluid embolism, not with abruptio placentae.

B. Puerperal infection: While any obstetric complication can potentially increase the risk of infection, the symptoms described (petechiae and bleeding around the IV site) are more indicative of a coagulation disorder.

C. Preeclampsia: Preeclampsia is a condition characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. It doesn’t typically cause petechiae and bleeding.

D. Disseminated intravascular coagulation (DIC): This is the correct choice. DIC is a serious disorder in which the proteins that control blood clotting become overactive. It can lead to excessive clotting and bleeding, which can cause petechiae and bleeding around the IV site. Abruptio placentae is a known risk factor for DIC. If suspected, it requires immediate medical attention.

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A nurse is caring for a client following an amniotomy, who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

Correct Answer is D

Explanation

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