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 B
Explanation
A. Incorrect. Weightbearing exercises should be avoided or limited during pregnancy, as they can increase the risk of injury, joint pain, and fatigue.
B. Correct. Moderate exercise can improve circulation, reduce swelling, and prevent varicose veins during pregnancy.
C. Incorrect. Resting for 30 minutes before each new exercise is not necessary and may reduce the benefits of physical activity.
D. Incorrect. Stretching exercises can help prevent muscle cramps, improve flexibility, and reduce back pain during pregnancy.
Correct Answer is B
Explanation
Choice A: Elevating the client's legs is a measure to increase blood flow to the brain in cases of orthostatic hypotension but may not be sufficient to improve fetal oxygenation in this situation. The lateral position is preferred as it improves uterine perfusion.
Choice B: The client's blood pressure of 80/40 mm Hg indicates hypotension, which can be a common side effect of epidural anesthesia. The priority nursing action is to place the client in a lateral (sidelying) position to improve blood flow to vital organs, including the uterus and placenta, and prevent further compromise of fetal oxygenation.
Choice C: Monitoring vital signs every 5 minutes is an important nursing action, but the priority in this situation is to address the hypotension and improve maternal and fetal wellbeing first.
Choice D: Notifying the provider is an important step, but it should not be the first action. Immediate intervention to address the hypotension is required to improve fetal oxygenation.
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