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 D
Explanation
Choice D reason: A client who has preeclampsia and reports epigastric pain and unresolved headache should be reported to the RN immediately, as these are signs of severe preeclampsia and impending eclampsia, which can lead to seizures, coma, and death. The client may need anticonvulsant medication, magnesium sulfate infusion, and delivery of the fetus.
Choice A reason: A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful may have preterm labor, which should be monitored and treated accordingly. However, this is not as urgent as choice D, as the contractions may subside with hydration, rest, or tocolytic medication.
Choice B reason: A client who has preeclampsia has 2+ patellar reflexes and 2+ proteinuria may have mild preeclampsia, which should be managed with antihypertensive medication, bed rest, and fetal monitoring. However, this is not as urgent as choice D, as the reflexes and proteinuria are not indicative of severe preeclampsia or eclampsia.
Choice C reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors may have a common side effect of terbutaline, which is a beta-adrenergic agonist that relaxes uterine smooth muscle and inhibits contractions. However, this is not as urgent as choice D, as the tremors are usually transient and benign. The nurse should monitor the client's vital signs, blood glucose, and fetal heart rate.
Correct Answer is D
Explanation
Choice A reason:
Bloody show from the vagina is incorrect, as this finding is normal and expected in the second stage of labor. Bloody show refers to the passage of mucus and blood from the cervix, which indicates cervical dilation and effacement.
Choice B reason:
Early decelerations in the FHR is incorrect, as this finding is normal and benign in the second stage of labor. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. The nurse should continue to monitor the FHR and document the findings.
Choice C reason:
Pelvic pressure with contractions is incorrect, as this finding is normal and expected in the second stage of labor. Pelvic pressure indicates that the fetus is descending into the birth canal and that the client is ready to push.
Choice D reason:
Uterine contraction lasting 2 min is correct, as this finding is abnormal and potentially dangerous in any stage of labor. Uterine contraction lasting 2 min can indicate uterine tetany or hyperstimulation, which can cause fetal distress, placental abruption, uterine rupture, or maternal hemorrhage. The nurse should report this finding to the provider immediately and prepare to intervene as ordered.
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