Detailed Answer Key Integration Practice 180 Question Test

Detailed Answer Key Integration Practice 180 Question Tes 1.A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? A. Maintain the client in the lithotomy position. Rationale: The lithotomy position is commonly used during delivery. With this position, the client reclines, and her legs are placed in stirrups. This client is only in the first stage of labor, so this would not be an appropriate position at this time. In addition, the client is encouraged to change positions during the labor process because this can relieve fatigue, increase comfort, and improve circulation. B. Perform vaginal examinations frequently. Rationale:Vaginal examination can introduce microorganisms into the vagina that can ascend into the amniotic sac. Frequent vaginal examinations after rupture of membranes increases the risk of infection and should be limited. C. Remind the client to bear down with each contraction. Rationale:A client in labor should not be encouraged to push or bear down until the cervix is completely dilated. This client is in the active phase of the first stage of labor. This means that her cervix will be between 0 and 7 cm dilated. It would not be appropriate to have her to push or bear down at this time. D. Encourage the client to empty her bladder every 2 hr. Rationale:A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client’s risk of postpartum hemorrhage.