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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Late decelerations in the fetal heart rate are often associated with uteroplacental insufficiency, and one of the first interventions is to improve uterine blood flow by changing the client's position. Placing the client in a left lateral position can help relieve pressure on the vena cava and improve blood flow to the placenta and the baby.
Choice B: Administering oxygen is a correct intervention for late decelerations, but it should follow the position change. Oxygen administration helps increase oxygen levels in the maternal blood, which can improve fetal oxygenation.
Choice C: Applying a fetal scalp electrode can provide continuous fetal heart rate monitoring, but it does not address the immediate concern of late decelerations. Position change and oxygen administration should be the priority.
Choice D: Increasing the rate of the IV infusion might not have an immediate effect on resolving late decelerations. Position change and oxygen administration should be the initial interventions.
Correct Answer is D
Explanation
Choice A: "I should not drink alcoholic beverages during my pregnancy." Correct, as alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders and other adverse outcomes.
Choice B: "I should drink about 2 liters of fluid each day." Correct, as adequate hydration is essential during pregnancy.
Choice C: "I can have a moderate amount of caffeine daily." Correct, as moderate caffeine consumption is generally considered safe during pregnancy (around 200300 mg per day).
Choice D: During pregnancy, certain fish types can be high in mercury, which can be harmful to the developing fetus. Fish with high mercury levels should be limited or avoided during pregnancy.
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