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?

Maintain the client in the lithotomy position.

Encourage the client to empty her bladder every 2 hr.

Remind the client to bear down with each contraction.

Perform vaginal examinations frequently,

Answer and Explanation

The Correct Answer is B

A. Maintain the client in the lithotomy position: The lithotomy position is not typically

maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B.   Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C.   Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D.   Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.

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Correct Answer is A

Explanation

Choice A: The client's symptoms of lightheadedness and tingling fingers indicate that she may be hyperventilating, which can occur when patternpaced breathing is too rapid. Breathing into a paper bag can help the client rebreathe some of the exhaled carbon dioxide, which can help correct the respiratory alkalosis caused by hyperventilation.

Choice B: Administering oxygen via nasal cannula may not address the underlying issue of hyperventilation. It is more appropriate to assist the client in slowing down her breathing pattern.

Choice C: Tucking the chin to the chest is not relevant to the client's symptoms of hyperventilation.

Choice D: Instructing the client to increase her respiratory rate would exacerbate the hyperventilation, leading to more symptoms of respiratory alkalosis.

A. Increase your intake of ironrich foods and take a prenatal vitamin. B. Avoid any alcohol consumption. C. Take a folic acid supplement for at least 3 months before you get pregnant. D. Avold all foods containing aspartame

Correct Answer is C

Explanation

A. "Increase your intake of ironrich foods and take a prenatal vitamin."
Important, but not directly related to reducing the risk of neural tube defects. Ironrich foods and prenatal vitamins are essential for overall maternal and fetal health, but they do not specifically target neural tube defect prevention.
B. "Avoid any alcohol consumption."
Important advice during pregnancy to prevent fetal alcohol spectrum disorders, but not directly related to reducing the risk of neural tube defects.
C. "Take a folic acid supplement for at least 3 months before you get pregnant."
Correct: Adequate folic acid intake before conception and during early pregnancy can significantly reduce the risk of neural tube defects in newborns.
D. "Avoid all foods containing aspartame."Aspartame is an artificial sweetener that has been studied for safety in pregnancy, and there is currently no strong evidence linking it to neural tube defects. However, it's still a good idea
to limit the intake of artificial sweeteners during pregnancy and focus on a balanced diet.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the first stage of labor and is using patternpaced breathing. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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