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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. After ceasing breastfeeding, the diaphragm should be resized: Breastfeeding can affect vaginal lubrication and elasticity. It might be advisable to have the diaphragm refitted after childbirth and after breastfeeding stops. However, this choice doesn't directly address the current situation.
B. Use an alternate form of contraception until a new diaphragm is obtained: This is a reasonable suggestion. Using a diaphragm that was fitted before pregnancy might not offer adequate protection due to potential changes in the cervix's size or shape after childbirth.
C. If no more than 20 pounds were gained during pregnancy, the diaphragm is safe to use: Weight gain during pregnancy can affect the size and shape of the vagina and cervix. However, specifying a particular weight gain as a safety criterion for using the diaphragm isn't entirely accurate.
D. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated: This is a cautious approach. Waiting until the diaphragm size is confirmed by a healthcare professional could be prudent to ensure the correct fit and effectiveness.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.