A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?

Apply perineal pressure to the emerging fetal head

Cut the umbilical cord

Prevent the perineum from tearing

Promote delivery of the placenta

Answer and Explanation

The Correct Answer is A

A. Correct. In rapidly progressing labor, applying gentle perineal pressure helps control the speed of delivery and can prevent or minimize perineal tearing or lacerations. It also helps to manage the delivery of the fetal head, especially in cases where the labor is very rapid which can cause neurologic damage (increased intracranial pressure and dural/subdural tearing).

B. Cutting the umbilical cord is not the priority in this situation. The focus should be on the immediate management of the delivery process and preventing complications related to perineal tearing.

C. Preventing the perineum from tearing: While preventing the perineum from tearing is important, it is not the immediate priority in the context of rapidly progressing labor. The primary focus should be on safely delivering the baby, which involves controlling the delivery of the fetal head to prevent complications.

D. Promoting the delivery of the placenta is a consideration for the third stage of labor, which follows the delivery of the baby. It is not the priority during the active phase of delivery.

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Correct Answer is B

Explanation

The correct answer is B. Massage the client's back.

A. Turning the client onto her left side may be a comfort measure, but it is not specifically associated with the gate control theory of pain. It may help improve blood flow and relieve pressure but does not directly engage the gate control mechanism.

B. Massage the client's back is consistent with the gate control theory of pain.

According to the gate control theory, non-painful input (such as massage) can close the "gate" to painful input, reducing the perception of pain. Massage stimulates large-diameter nerve fibers, which can inhibit the transmission of painful signals.

C. Encouraging the client to rest between contractions is a general comfort measure but is not directly related to the gate control theory of pain.

D. Administering prescribed analgesic medication is a pharmacological approach to pain management and is not specifically associated with the gate control theory. Medications can act on pain receptors but do not engage the gate control mechanism.

A. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor B. An excessive amount of amniotic fluid is present C. There is an elevated level of alpha fetoprotein (AFP) in the amniotic fluid. D. The client is carrying more than one fetus

Correct Answer is B

Explanation

The correct answer is B. An excessive amount of amniotic fluid is present.

A. Polyhydramnios is primarily characterized by an increased volume of amniotic fluid, and it is not directly linked to congenital anomalies, growth restriction, or fetal distress. However, it can be associated with certain conditions that affect fetal swallowing or the production of amniotic fluid.

B. Correct. Polyhydramnios refers to an abnormal increase in the amount of amniotic fluid surrounding the fetus. This condition can result from various factors, such as fetal anomalies, maternal diabetes, or gastrointestinal malformations in the fetus that affect the swallowing of amniotic fluid.

C. An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid is associated with neural

tube defects, not polyhydramnios.

D. Carrying more than one fetus (multifetal gestation) can be associated with an increased risk of polyhydramnios due to factors such as increased fetal urine production, but the presence of polyhydramnios does not necessarily indicate a multifetal pregnancy.

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A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Correct Answer is B

Explanation

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

Correct Answer is B

Explanation

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