A nurse is caring for a client who was in the first stage of labor and is encouraging the client to void every two hours. Which of the following statements should the nurse make?
A distended bladder will be traumatized by frequent pelvic exams
A distended bladder reduces pelvic space needed for birth.
A full bladder increases the risk for fetal trauma trauma
A full bladder increases the risk for bladder infections
The Correct Answer is B
The correct answer is B. A distended bladder reduces pelvic space needed for birth.
A. A distended bladder itself is not typically traumatized by pelvic exams. However, a full bladder can impede the progress of labor and may affect the accuracy of pelvic exams.
B. This statement is accurate. A distended bladder can reduce the available pelvic space needed for the descent of the baby during labor. An empty bladder allows the fetal head to engage more easily in the pelvis.
C. A full bladder is not directly associated with an increased risk for fetal trauma. The primary concern is the impact on pelvic space and the progress of labor.
D. While a full bladder can contribute to urinary tract infections, it is not the primary reason for encouraging the client to avoid a distended bladder during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Applying sacral counterpressure is appropriate. In the right occiput posterior position, the fetal head is positioned towards the mother's back, leading to increased pressure on the sacral are
A. Applying sacral counterpressure can help alleviate back pain during contractions.
Choice B Reason:
Performing transcutaneous electrical nerve stimulation (TENS) is inappropriate. While TENS can be used for pain relief in labor, applying sacral counterpressure is a more specific intervention for back pain related to fetal positioning.
Choice C Reason:
Initiating slow-paced breathing is inappropriate. While slow-paced breathing is a coping mechanism during contractions, it may not specifically address the back pain associated with the fetus in the right occiput posterior position.
Choice D Reason:
Assisting with biofeedback is inappropriate. Biofeedback is not a standard intervention for managing back pain during labor, especially in the context of fetal positioning. Sacral counterpressure is a more direct approach for this situation.
Correct Answer is C
Explanation
Choice A Reason:
Placing the client in a supine position for 30 minutes following the first dose of anesthetic solution is not a standard recommendation. The positioning during epidural placement is typically a seated or side-lying position.
Choice B Reason:
Administering 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution is not a standard practice for epidural anesthesi
A. Fluids may be administered, but the type and volume depend on the patient's individual needs and the healthcare provider's orders.
Choice C Reason:
Monitoring the client's blood pressure every minute following the first dose of anesthetic solution is appropriate. Epidural anesthesia can potentially cause hypotension (low blood pressure), which is a common side effect. Therefore, close monitoring of the client's blood pressure is crucial, especially following the administration of the initial dose of the anesthetic solution. The goal is to promptly detect and manage any decrease in blood pressure to ensure the well-being of both the mother and the baby.
Choice D Reason:
Ensuring the client has been NPO (nothing by mouth) for 4 hours prior to the placement of the epidural and the first dose of anesthetic solution is not a specific requirement for epidural anesthesi
A. NPO status is more relevant to surgical procedures involving general anesthesia and is not typically a strict requirement for epidural placement.
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