A nurse is caring for a client who is about to deliver a baby.
Which of the following responses should the nurse make?
The nurse should prepare for a cesarean birth
The nurse should check the client’s temperature every 8 hours
The nurse should encourage the client to empty the bladder every 2 hours
The nurse should remind the client to bear down with each contraction
The Correct Answer is D
Choice A rationale:
Cesarean birth is a surgical procedure that is only performed when there is a medical indication for it. It is not the standard of
care for all women who are about to deliver a baby.
In the absence of any specific information indicating a need for cesarean birth, it would be premature for the nurse to prepare
for one.
Choice B rationale:
Checking the client's temperature every 8 hours is part of routine postpartum care.
However, it is not a priority intervention during the active labor phase when the client is about to deliver.
The nurse's focus should be on supporting the client through the delivery process.
Choice C rationale:
Encouraging the client to empty the bladder every 2 hours is important for comfort and to prevent urinary retention.
However, it is not a priority intervention during the active labor phase.
The client may not feel the urge to urinate frequently due to the pressure of the baby's head on the bladder.
Choice D rationale:
Reminding the client to bear down with each contraction is the most appropriate nursing intervention at this time.
Bearing down helps to move the baby down the birth canal and can shorten the duration of labor.
The nurse can provide verbal cues and physical support to help the client bear down effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
2+ patellar reflex: A hyperactive patellar reflex (also known as a knee-jerk reflex) is a sign of hyperreflexia, which can be a neurological symptom of preeclampsia. Hyperreflexia results from heightened nerve excitability and can manifest as exaggerated reflexes. In preeclampsia, it stems from central nervous system irritability due to cerebral edema or other neurological disturbances.
2+ proteinuria: Proteinuria, defined as the presence of excessive protein in the urine, is a hallmark sign of preeclampsia. It indicates glomerular damage in the kidneys, leading to protein leakage into the urine. The degree of proteinuria is graded on a scale of 1+ to 4+, with 2+ representing a significant level that warrants immediate attention.
Choice B rationale:
24 weeks of gestation: While 24 weeks of gestation is considered early preterm birth, it is not inherently a finding that requires immediate reporting to the RN in the context of postpartum care. The focus on the postpartum unit is primarily on the health of the mother and newborn after delivery, rather than managing ongoing pregnancies.
Choice C rationale:
Preeclampsia: While preeclampsia is a serious condition that necessitates close monitoring and management, the mere diagnosis of preeclampsia without additional concerning findings does not automatically require immediate reporting to the RN. It's essential to assess for specific signs and symptoms that indicate worsening or complications of preeclampsia, such as those mentioned in Choice A.
Choice D rationale:
Heart rate of 100/min: A heart rate of 100 beats per minute is within the normal range for adults, even postpartum. Mild tachycardia (increased heart rate) can be a physiological response to various factors such as pain, anxiety, or exertion, and it does not always signify a serious problem. However, if the heart rate is persistently elevated or accompanied by other concerning symptoms, it would warrant further evaluation.
Correct Answer is B
Explanation
Choice A rationale:
Increasing fluid intake is not the priority action in this situation. While maintaining adequate hydration is important for
postpartum recovery, it does not directly address the immediate concern of excessive bleeding. Excessive fluid intake could
potentially worsen the bleeding by increasing blood volume and potentially increasing blood pressure.
Choice C rationale:
Helping the client use the bedpan to urinate is not the priority action in this case. While a full bladder can sometimes interfere
with uterine contraction and contribute to postpartum bleeding, it is not the most likely cause of the excessive bleeding in this
scenario. The client has already saturated two perineal pads in a short period, indicating a more significant bleeding issue that
needs to be addressed first.
Choice D rationale:
Preparing to administer tocolytic medication is not the appropriate action at this time. Tocolytic medications are used to stop
contractions, but they are not typically used to manage postpartum hemorrhage. In fact, tocolytics could potentially worsen
the bleeding by interfering with the natural mechanisms that help the uterus contract and stop bleeding after delivery.
Choice B rationale:
Checking the consistency of the client's uterine fundus is the priority action in this situation. The most common cause of
postpartum hemorrhage is uterine atony, which means the uterus is not contracting effectively to clamp down on the blood
vessels where the placenta was attached. A soft, boggy fundus is a sign of uterine atony. By assessing the fundus, the nurse can
quickly determine if uterine atony is the likely cause of the bleeding and take appropriate interventions to manage it.
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