The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?
Review the fetal heart rate pattern
Check the pH of the vaginal fluid
Determine cervical dilation.
Palpate the client's bladder
The Correct Answer is D
A. Review the fetal heart rate pattern: Checking the fetal heart rate (FHR) pattern is crucial during labor to ensure the baby is tolerating labor well and there are no signs of fetal distress. However, when the client expresses a need to use the bathroom, this may not be the immediate action required.
B. Check the pH of the vaginal fluid: Checking the pH of the vaginal fluid is not typically an initial action when a laboring client expresses a need to go to the bathroom. Monitoring the pH may be relevant for various reasons, but it's not a primary consideration in this context.
C. Determine cervical dilation: The initial examination revealed the cervix was 3 cm dilated. While reassessing the cervical dilation could provide information about the progress of labor, it may not be the most immediate action needed when the client wants to use the bathroom.
D. Palpate the client's bladder: This is the most relevant action when a laboring client expresses a desire to go to the bathroom. Palpating the bladder can help determine if it's full, which is important because a full bladder might impede labor progress or cause discomfort during contractions.
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Related Questions
Correct Answer is C
Explanation
A. Dilate the pupil so the red reflex can be visualized:
This statement is not accurate regarding the purpose of the eye ointment. The eye ointment is not used to dilate the pupil but serves a different purpose.
B. Prevent herpes infection:
While eye ointment can help prevent certain eye infections, it's not specifically administered to prevent herpes infection.
C. Prevent eye infections:
This is the correct answer. The eye ointment typically contains an antibiotic and is applied to prevent infections, particularly those that could be transmitted during childbirth.
D. Clear the infant's vision:
The eye ointment is not used to clear the infant's vision. Its primary purpose is to prevent infections rather than affect vision.
Correct Answer is C
Explanation
Calcium:
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Iron:
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
Folic acid:
Folic acid is vital for preventing neural tube defects, including anencephaly. It's recommended for women of childbearing age and especially during the early stages of pregnancy.
Vitamin D:
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
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