A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?
Observe for the presence of a nuchal cord.
Prepare to administer oxytocin.
Observe for crowning.
Apply fundal pressure.
The Correct Answer is C
A. Observe for the presence of a nuchal cord: While this is important, it is not specifically related to the finding of the fetal head at a certain station.
B. Prepare to administer oxytocin: Oxytocin is a hormone used to induce or augment labor, but there is no indication for its use based solely on the fetal head station.
C. Observe for crowning: The fetal head at 3+ station indicates significant descent, and crowning may occur soon. Crowning is the appearance of the fetal head at the vaginal opening and indicates that delivery is imminent.
D. Apply fundal pressure: Fundal pressure is not appropriate at this stage of labor and could cause harm.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Increasing the rate of infusion of the IV oxytocin would worsen the uterine hyperstimulation and fetal distress that are indicated by the frequent, long, and strong contractions and uniform decelerations.
B. Correct. Discontinuing the infusion of the IV oxytocin would stop the uterine hyperstimulation and allow the fetus to recover from hypoxia.
C. Incorrect. Decreasing the rate of infusion of the maintenance IV solution would not affect the uterine hyperstimulation or fetal distress, as they are caused by the oxytocin, not by the fluid volume.
D. Incorrect. Slowing the client's rate of breathing would not help with the uterine hyperstimulation or fetal distress, as they are not related to maternal hyperventilation or respiratory alkalosis.
Correct Answer is A
Explanation
Choice A: Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which play a crucial role during childbirth. Strengthening these muscles can aid in better control during labor and delivery, facilitating stretching and reducing the risk of injury.
Choice B: Kegel exercises do not have a direct impact on preventing constipation during pregnancy. However, they may help improve bowel control and prevent fecal incontinence.
Choice C: While Kegel exercises can improve posture and core strength, their primary benefit lies in strengthening the pelvic muscles, not directly reducing backaches throughout pregnancy.
Choice D: Kegel exercises are not intended to prevent stretch marks on the abdomen. Stretch marks are caused by the stretching of the skin during pregnancy and are not related to pelvic muscle exercises.
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