A nurse is assisting with the care of a client who is in labor and has the urge to push.
Which of the following instructions should the nurse give the client?
You should push continuously throughout the entire contraction
Take a deep, cleansing breath before and after each contraction
I will let you know when you should push according to your contractions
Hold your breath and push while I count to ten
The Correct Answer is B
Choice A rationale:
Pushing continuously throughout the entire contraction can lead to maternal exhaustion and may not be the most effective way to progress labor. It’s important for the mother to conserve her energy and work with her body’s natural rhythms.
Choice B rationale:
Taking a deep, cleansing breath before and after each contraction can help the mother manage pain and keep her energy up.
This technique is often recommended because it allows the mother to rest briefly and gather strength for the next contraction.
Choice C rationale:
While it’s important for the nurse to monitor contractions and provide guidance, the urge to push is a natural response that
can vary among individuals. Telling the mother when to push according to contractions may not align with her body’s natural
instincts.
Choice D rationale:
Holding one’s breath and pushing while someone counts to ten is an outdated practice. This method can cause unnecessary
strain and doesn’t take into account the individual rhythms and responses of the mother’s body.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The presence of a “bloody show” from the vagina is a normal part of labor. It’s caused by the expulsion of the mucus plug that
has sealed the cervix during pregnancy. This is a common occurrence and does not need to be reported to the provider.
Choice B rationale:
Early decelerations in the Fetal Heart Rate (FHR) are usually not a cause for concern. They are often a sign of head
compression, which is a normal occurrence during labor. Therefore, this finding does not need to be reported to the provider.
Choice C rationale:
Uterine contractions lasting 2 minutes could be a sign of a complication known as “uterine tachysystole” or “hyperstimulation”. This condition can reduce oxygen supply to the baby and may require medical intervention. Therefore, this finding should be reported to the provider.
Choice D rationale:
Feeling pelvic pressure with contractions is a normal part of the second stage of labor. This pressure is due to the baby moving
down into the birth canal. Therefore, this finding does not need to be reported to the provider.
Correct Answer is B
Explanation
Rationale for Choice A:
Checking the client's fundus is an important assessment in the postpartum period, but it is not the most immediate action
when a large amount of lochia rubra with clots is present. A boggy or displaced fundus could indicate subinvolution or
hemorrhage, but these are not the most likely causes of the presenting symptoms.
Rationale for Choice B:
Performing a vaginal examination is the most appropriate first action in this situation. This will allow the nurse to directly
assess the source and amount of bleeding, as well as to check for any retained placental fragments or cervical lacerations.
These findings could be the cause of the lochia rubra and clots, and prompt intervention may be necessary.
Rationale for Choice C:
While measuring the client's vital signs is an important part of the postpartum assessment, it is not the most immediate action
when there is evidence of active bleeding. Taking vital signs can be delayed while the nurse performs a vaginal examination to
assess the source and severity of the bleeding.
Rationale for Choice D:
Checking for a full bladder is not the most relevant action in this situation. A full bladder can contribute to postpartum
discomfort, but it is not likely to be the cause of the lochia rubra and clots. Addressing the bleeding should be the priority.
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