A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take?
Inform the client that she can go to the bathroom whenever needed.
Evaluate the side effects of analgesia used during labor.
Advise the client to remain in bed for the next few hours.
Assist the client to the bathroom using a wheelchair.
The Correct Answer is B
Choice A reason: Inform the client that she can go to the bathroom whenever needed is incorrect, as this action can put the client at risk of injury or complications. The client may experience orthostatic hypotension, dizziness, weakness, or bleeding after a vaginal birth, which can impair their ability to ambulate safely and independently. The nurse should assist the client to the bathroom and monitor their vital signs and lochia.
Choice B reason: This is the correct action. The nurse should assess the client for any residual effects of analgesia, such as dizziness or unsteadiness, which could increase the risk of falls if the client tries to get up.
Choice C reason: Advise the client to remain in bed for the next few hours is incorrect, as this action can increase the risk of bladder distension, infection, or thrombosis. The nurse should encourage and assist the client to ambulate early and frequently after a vaginal birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.
Choice D reason: While assisting the client is a good approach, it is important to first evaluate her condition to ensure it is safe for her to get out of bed. If she has been assessed and is deemed safe to ambulate, assisting her to the bathroom with support might be appropriate. However, the initial step is to assess her condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice B reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines is correct, as this follows the correct order and measurement of cervical assessment. Cervical dilation, effacement, and station are recorded in that order to describe the progress of labor. Station refers to the relationship between the presenting part of the fetus and the maternal pelvis, measured by the level of the ischial spines. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
Choice C reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice D reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not match the documentation of station. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
Correct Answer is B
Explanation
Choice A reason: Inform the client that she can go to the bathroom whenever needed is incorrect, as this action can put the client at risk of injury or complications. The client may experience orthostatic hypotension, dizziness, weakness, or bleeding after a vaginal birth, which can impair their ability to ambulate safely and independently. The nurse should assist the client to the bathroom and monitor their vital signs and lochia.
Choice B reason: This is the correct action. The nurse should assess the client for any residual effects of analgesia, such as dizziness or unsteadiness, which could increase the risk of falls if the client tries to get up.
Choice C reason: Advise the client to remain in bed for the next few hours is incorrect, as this action can increase the risk of bladder distension, infection, or thrombosis. The nurse should encourage and assist the client to ambulate early and frequently after a vaginal birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.
Choice D reason: While assisting the client is a good approach, it is important to first evaluate her condition to ensure it is safe for her to get out of bed. If she has been assessed and is deemed safe to ambulate, assisting her to the bathroom with support might be appropriate. However, the initial step is to assess her condition.
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