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 C
Explanation
A) Variable decelerations are a result of the administration of IV narcotic analgesics: IV narcotic analgesics can cause changes in the fetal heart rate, but they are more commonly associated with early decelerations, not variable decelerations.
B) Variable decelerations are related to fetal head compression: Fetal head compression is associated with early decelerations, not variable decelerations.
C) Variable decelerations are due to umbilical cord compression: This is the correct answer.
Variable decelerations occur due to compression of the umbilical cord during contractions, leading to transient decreases in fetal blood flow and oxygenation.
D) Variable decelerations are caused by uteroplacental insufficiency: Uteroplacental insufficiency is associated with late decelerations, not variable decelerations.
Correct Answer is D
Explanation
Choice A: Fetal lung maturity is not assessed through maternal serum alphafetoprotein testing. It is usually evaluated through tests such as amniocentesis or specialized ultrasound examinations closer to the third trimester.
Choice B: The maternal serum alphafetoprotein test specifically screens for certain birth defects and genetic conditions in the fetus, rather than general signs of physical and physiological
wellbeing.
Choice C: The maternal serum alphafetoprotein test is not used to identify Rh incompatibility. Rh incompatibility is determined through blood tests that assess the Rh factor of the mother's blood and the Rh status of the baby.
Choice D: The maternal serum alphafetoprotein test is a blood screening test that can identify neural tube defects (such as spina bifida) and chromosomal abnormalities (such as Down syndrome) in the fetus. The test measures the levels of alphafetoprotein in the mother's blood, and abnormal levels may indicate the need for further diagnostic testing.
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