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 C
Explanation
Choice A Reason:
"I will get injections of the medication once daily until my labor stops." Terbutaline is typically administered as a subcutaneous injection or orally, but the frequency can vary. It is often given as needed or on a scheduled basis, depending on the healthcare provider's instructions. However, "once daily until labor stops" is not a typical approach.
Choice B Reason:
"My blood sugar may be low while I'm on this medication." While terbutaline can affect glucose metabolism, it is more commonly associated with hyperglycemia (high blood sugar) rather than hypoglycemia (low blood sugar).
Choice C Reason:
"I will have blood tests because my potassium might decrease." Terbutaline, a beta-2 adrenergic agonist, can potentially lead to hypokalemia (a decrease in potassium levels). Monitoring potassium levels through blood tests is important during terbutaline therapy.
Choice D Reason:
"My blood pressure may increase while I'm on this medication." Terbutaline is known to cause cardiovascular side effects, but an increase in blood pressure is not a common effect. It is more associated with tachycardia (increased heart rate) and potential hypotension. Monitoring blood pressure is still important, but an increase is less likely compared to other cardiovascular effects.
Correct Answer is C
Explanation
A. The pattern of contractions is important in assessing labor, but the presence of regular contractions alone does not confirm true labor. It is the changes in the cervix that indicate progress in labor.
B. The station of the presenting part (the level at which the baby's head has descended into the pelvis) is also a factor in labor, but it is not the primary indicator of true labor. Changes in the cervix are more indicative.
C. Changes in the cervix are a key sign of true labor.
True labor involves cervical effacement (thinning) and dilation (opening). These changes in the cervix signify progress in the labor process.
D. Rupture of the membranes (water breaking) can be a sign of labor, but it doesn't confirm true labor on its own. It might occur before, during, or after labor has begun.
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