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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) All of the clients: Maternal serum alphafetoprotein (MSAFP) screening is a routine prenatal test offered to all pregnant women, usually between 15 and 20 weeks of gestation. It is used to screen for certain fetal anomalies, including neural tube defects such as spina bifida and anencephaly. Regardless of a client's medical history or risk factors, the MSAFP screening is typically recommended for all pregnant individuals as part of routine prenatal care.
B) A client who has a history of preterm labor: Preterm labor history is not a specific indication for MSAFP screening. This test is primarily used to screen for fetal anomalies, not preterm labor risk assessment.
C) A client who has mitral valve prolapse: Mitral valve prolapse is also not an indication for MSAFP screening. The test is focused on assessing fetal health and not maternal heart conditions.
D) A client who has been exposed to AIDS: MSAFP screening is not related to maternal exposure to AIDS. It is a test focused on assessing the fetus's risk of certain congenital abnormalities.
Correct Answer is C
Explanation
Choice A: While relaxation can be helpful during a pelvic examination, it is not the most comprehensive response to address the client's concerns.
Choice B: A pelvic examination is not always required for prescribing birth control pills. In many cases, a healthcare provider can prescribe oral contraceptives based on the client's medical history and other factors without a pelvic exam.
Choice C: This response encourages the client to express her specific concerns and fears related to the examination, allowing the nurse to address them directly and provide appropriate support and reassurance.
Choice D: Although offering support during the exam is important, it does not address the client's nervousness and concerns about the examination itself.
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