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 D
Explanation
The correct answer is: April 11, 2016
Choice A: April 27, 2016
Reason: Using Naegele’s Rule, the estimated date of delivery (EDD) is calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). For an LMP of May 4, 2015:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 27, 2016, is incorrect because it does not follow the correct calculation steps.
Choice B: April 11, 2016
Reason: Following Naegele’s Rule:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 11, 2016, is the correct EDD as it accurately follows the calculation steps.
Choice C: February 27, 2016
Reason: This date is incorrect because it does not follow the correct calculation steps of Naegele’s Rule. The correct EDD should be in April, not February.
Choice D: February 11, 2016
Reason: This date is also incorrect. While it follows the initial steps of Naegele’s Rule, it does not account for the full calculation, which should result in an April date, not February.
Correct Answer is C
Explanation
A) Variable decelerations are a result of the administration of IV narcotic analgesics: IV narcotic analgesics can cause changes in the fetal heart rate, but they are more commonly associated with early decelerations, not variable decelerations.
B) Variable decelerations are related to fetal head compression: Fetal head compression is associated with early decelerations, not variable decelerations.
C) Variable decelerations are due to umbilical cord compression: This is the correct answer.
Variable decelerations occur due to compression of the umbilical cord during contractions, leading to transient decreases in fetal blood flow and oxygenation.
D) Variable decelerations are caused by uteroplacental insufficiency: Uteroplacental insufficiency is associated with late decelerations, not variable decelerations.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.