A nurse is caring for a client who is in active labor and has just been examined as being at 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?
"Assist the client into a more comfortable position."
"Observe the perineum for signs of crowning."
"Have the client pant or blow during the next contractions to help her refrain from pushing."
"Help the client to the bathroom to empty her bladder."
The Correct Answer is C
Choice A: At 7 cm dilation, the client is in active labor, and assisting her into a more comfortable position may not be appropriate at this stage. It is essential to observe for signs of impending birth and assess the progress of labor.
Choice B: Crowning is assessed only once full dilation occurs. At 7 cm, this is premature and distracts from interventions that prevent injury from early pushing.
Choice C: Panting or blowing helps suppress the urge to push until full dilation, protecting the cervix and reducing complications. This is the evidence-based intervention recommended in labor management guidelines.
Choice D: While emptying the bladder is generally recommended during labor to provide more room for the baby to descend, the client's current urge to push suggests that the baby is likely in a lower position, and it might not be safe or feasible to move the client to the bathroom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Variable decelerations on the fetal heart rate monitor tracing are suggestive of umbilical cord compression. These decelerations are often V, U, or Wshaped, and their onset, depth, and duration can vary. They are associated with cord compression, which can reduce blood flow to the fetus during contractions. Other options are as follows:
Choice B: Late decelerations are indicative of uteroplacental insufficiency and are not related to umbilical cord problems.
Choice C: Accelerations are reassuring and suggest a responsive, healthy fetus.
Choice D: Early decelerations are usually benign and result from head compression during contractions, not umbilical cord issues.
Correct Answer is D
Explanation
Choice A: Smoking is not directly associated with the development of type 1 diabetes mellitus in the baby.
Choice B: While smoking during pregnancy can have various effects on the baby's health, hearing loss is not one of the common complications.
Choice C: Although smoking during pregnancy is associated with an increased risk of congenital heart defects, intrauterine growth restriction is a more likely complication based on the client's smoking history.
Choice D: Smoking during pregnancy is associated with various adverse outcomes for both the mother and the baby. It can cause intrauterine growth restriction (IUGR), where the baby does not grow at the expected rate and has a lower birth weight. Smoking reduces blood flow to the placenta, which can affect the baby's growth and development.
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