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 C

Explanation

A. The client requires a rubella vaccination at this time. This is incorrect because rubella vaccination is contraindicated during pregnancy due to the risk of congenital rubella syndrome. Vaccination should be administered postpartum.

B. The client is not experiencing a rubella infection at this time. While this statement is true, it does not address the need for future immunization, which is the critical aspect of the interpretation.

C. The client requires a rubella immunization following delivery. This is correct because a negative rubella titer indicates that the client is not immune to rubella and should receive the vaccine postpartum to prevent future infection.

D. The client is immune to the rubella virus. This is incorrect because a negative rubella titer indicates a lack of immunity to rubella, meaning the client is susceptible to infection.

A. "You can continue your moderate daily jogging as long as you stay hydrated, don't push yourself too hard, and don't get overheated." B. "Activities that consistently raise your body temperature, such as saunas and hot tubs, are safe until the third trimester." C. "It is recommended that pregnant clients limit their exercise to only stretching while lying flat on a mat several times a week." D. "Exercising during pregnancy is not recommended at all."

Correct Answer is A

Explanation

A: Engaging in moderate physical activity during pregnancy, such as jogging, is generally safe and beneficial for pregnant women who have uncomplicated pregnancies. Staying hydrated, avoiding excessive exertion, and preventing overheating are important considerations during exercise.

B: The use of saunas and hot tubs during pregnancy is generally not recommended at any trimester, as they can cause hyperthermia and pose risks to the developing fetus.

C: Limiting exercise to only stretching on a mat is not appropriate during pregnancy. Regular physical activity is generally encouraged, provided there are no specific contraindications or complications.

D: Completely avoiding exercise during pregnancy is not recommended, as moderate and appropriate physical activity can have various benefits for both the mother and the baby.

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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 an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

Correct Answer is C

Explanation

A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

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A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?

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