A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?

Prepare equipment needed for newborn resuscitation

Perform endotracheal suctioning as soon as the fetal head is delivered

Prepare the client for an ultrasound examination

Prepare the client for an emergency cesarean birth

Answer and Explanation

The Correct Answer is A

A. Prepare equipment needed for newborn resuscitation.

A. Preparing equipment needed for newborn resuscitation is the correct action.

Meconium-stained amniotic fluid can increase the risk of meconium aspiration syndrome in the newborn. While the fetal heart rate is reassuring, being prepared for potential newborn resuscitation is prudent given the meconium staining.

B. Performing endotracheal suctioning as soon as the fetal head is delivered is not the current standard of care. The American Academy of Pediatrics (AAP) no longer recommends routine suctioning of meconium-stained infants unless they show signs of respiratory distress, poor muscle tone, or a depressed heart rate.

C. Preparing the client for an ultrasound examination is not the immediate priority. Meconium-stained amniotic fluid may be associated with fetal distress, but the focus should be on the current labor and delivery situation.

D. Preparing the client for an emergency cesarean birth is not the first action.

The presence of meconium staining alone does not necessarily indicate the need for an emergency cesarean birth, especially if the fetal heart rate is reassuring.

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Correct Answer is B

Explanation

The correct answer is B. Massage the client's back.

A. Turning the client onto her left side may be a comfort measure, but it is not specifically associated with the gate control theory of pain. It may help improve blood flow and relieve pressure but does not directly engage the gate control mechanism.

B. Massage the client's back is consistent with the gate control theory of pain.

According to the gate control theory, non-painful input (such as massage) can close the "gate" to painful input, reducing the perception of pain. Massage stimulates large-diameter nerve fibers, which can inhibit the transmission of painful signals.

C. Encouraging the client to rest between contractions is a general comfort measure but is not directly related to the gate control theory of pain.

D. Administering prescribed analgesic medication is a pharmacological approach to pain management and is not specifically associated with the gate control theory. Medications can act on pain receptors but do not engage the gate control mechanism.

A. Help the client to the bathroom to void B. Observe the perineum for signs of crowning C. Have the client pant during the next contractions D. Assist the client into a comfortable position

Correct Answer is C

Explanation

A. Helping the client to the bathroom to void is not the priority in this situation. The urge to push could indicate that the baby is descending, and the nurse should be prepared for imminent delivery.

B. Observing the perineum for signs of crowning is a valid action, but having the client pant during contractions is more appropriate at this stage. It can help prevent rapid descent and potential trauma if delivery is imminent.

C. Having the client pant during the next contractions is the correct action.

Panting during contractions may slow down the urge to push and prevent rapid delivery, especially if the healthcare provider is not present or the delivery is not imminent.

D. Assisting the client into a comfortable position is important, but the priority is to manage the urge to push. Panting can be an effective technique for delaying pushing until the healthcare provider is ready for the delivery.

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A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Correct Answer is B

Explanation

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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