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.
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Related Questions
Correct Answer is D
Explanation
The correct answer is D. Variable decelerations.
A. Accelerations in the fetal heart rate are generally considered reassuring. Accelerations are an indication of fetal well-being and are often seen in response to fetal movement.
B. Early decelerations are typically associated with head compression during contractions and are considered a normal response to the pressure on the fetal head.
C. Late decelerations are indicative of uteroplacental insufficiency.
Late decelerations occur after the peak of the contraction and are associated with inadequate oxygenation to the fetus. This pattern raises concerns about the baby's well-being.
D. Variable decelerations are associated with umbilical cord compression.
Variable decelerations are abrupt decreases in the fetal heart rate that vary in duration, depth, and timing. They often coincide with contractions and suggest compression or occlusion of the umbilical cord.
Correct Answer is B
Explanation
The correct answer is B. Position the client with one hip elevated.
A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.
B. Positioning the client with one hip elevated is the priority action.
The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.
C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.
D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.
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