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,
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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Related Questions
Correct Answer is A
Explanation
A. Fetal position is persistent occiput posterior: The occiput posterior position (the back of
the baby's head facing the mother's back) can lead to a more challenging and prolonged labor with intense back pain.
B. Fetal attitude is in general flexion: Flexion is the normal fetal attitude for birth and does not contribute to a difficult labor with backache.
C. Fetal lie is longitudinal: Longitudinal lie refers to the baby's position along the mother's spine, but it doesn't specify the position of the baby's back, so it is not directly related to backache.
D. Maternal pelvis is gynecoid: Gynecoid pelvis is the most favorable pelvis shape for childbirth, so it is not likely to cause difficult labor with severe backache.
Correct Answer is B
Explanation
Choice A: This response is dismissive and does not validate the client's feelings. It may not address the client's concerns effectively.
Choice B: This response validates the client's feelings and reassures her that ambivalent feelings about pregnancy are common. It provides a supportive approach and normalizes her emotions.
Choice C: While counseling might be helpful for some clients, suggesting it immediately without further assessment of the client's needs may not be the most appropriate response at this stage.
Choice D: Encouraging the client to discuss her feelings with her mother may not be suitable, as the client might prefer professional support or may not have a positive relationship with her
mother. It is essential to avoid making assumptions about the client's support system and address her concerns empathetically.
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