A nurse is caring for a client who is in active labor with 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 comfortable position.

Observe the perineum for signs of crowning.

Have the client pant during the next contractions.

Help the client to the bathroom to void.

Answer and Explanation

The Correct Answer is C

Choice A reason:

While positioning is important for comfort during labor, addressing the immediate urge to push takes priority. Panting during contractions is the appropriate action.

Choice B reason:

Although observing for crowning is important when the client is close to delivery, the nurse should first intervene to address the client's urge to push since the client is only 7 cm dilated.

Choice C reason:

When a laboring client feels the urge to push but is not yet fully dilated (10 cm), encouraging her to pant can help reduce the urge to push and avoid complications, such as cervical swelling or tearing. This breathing technique helps the client delay pushing until full dilation and readiness of the cervix.
Choice D reason:

Assisting the client to the bathroom would not be appropriate at this stage of labor because the urge to push could lead to unsafe delivery outside the appropriate setting, and movement could increase discomfort or risks.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Right occiput posterior position: This position refers to the baby's head being down but facing the mother's back, which can make labor more challenging but is not a contraindication for amniotomy.

B. -2 station: This indicates that the baby's head is not yet engaged in the pelvis. While it can complicate labor, it is not an absolute contraindication for amniotomy, though caution is advised.

C. Cephalic presentation: This is the most common and favorable position for delivery, where the baby's head is down and ready for birth. It is not a contraindication for amniotomy.

D. Dilation less than 3 cm: This is a contraindication for amniotomy because the cervix is not sufficiently dilated, which can increase the risk of complications such as infection or prolonged labor.

A. Babinski's Reflex. B. Stepping Reflex. C. Moro reflex. D. Plantar Grasp reflex.

Correct Answer is A

Explanation

Choice A reason:

Babinski's Reflex is the normal response in infants when the sole of the foot is stroked from the heel to the ball of the foot. The big toe moves upward or toward the top surface of the foot, and the other toes fan out. This reflex is normal in children up to 2 years old, and it disappears as the nervous system matures. It may indicate damage to the central nervous system in older children and adults.

Choice B reason:

Stepping Reflex is the normal response in infants when they are held upright with their feet touching a flat surface. They will lift one foot and then the other, as if they are walking. This reflex is present at birth and lasts for about 2 months. It helps prepare the infant for voluntary walking.

Choice C reason:

Moro Reflex is the normal response in infants when they are startled by a loud noise or a sudden movement. They will extend their arms and legs, open their hands, and then curl up and bring their arms together as if they are hugging themselves. This reflex is present at birth and lasts for about 4 to 6 months. It is thought to be a protective response that helps the infant cling to their caregiver.

Choice D reason:

Plantar Grasp Reflex is the normal response in infants when pressure is applied to the sole of the foot near the toes. The toes will curl down and grasp the stimulus. This reflex is present at birth and lasts for about 9 to 12 months. It is similar to the palmar grasp reflex in the hands, and it helps develop the muscles and nerves in the feet. Some additional sentences are:. If you are interested in learning more about infant development, you can check out some of these links:. • [A guide to newborn reflexes]. • [A video demonstration of newborn reflexes].

View Question and Answer

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

A nurse is caring for a client who is in active labor with 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands which condition is a contraindication for an amniotomy.

Correct Answer is D

Explanation

What reflex is elicited: Fanning of toes when stroking lateral edge of baby's foot?

Correct Answer is A

Explanation

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?

Which maternal event is abnormal in the early postpartum period?

A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who:

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

The student nurse learns that the hormone necessary for milk production is

The most appropriate time for the nurse to encourage a laboring woman to push is during

After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests?

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?