Chapter 14- Nursing Management During Labor and Birth NCLEX Questions

When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? a) Hold your breath and push through entire contraction. b) Use chest-breathing with the contraction. c) Pant and blow during each contraction. d) Wait until you feel the urge to push. - The correct response is D, since nondirected pushing, based on current research, leads to better outcomes for both mother and infant. Holding breath and pushing throughout the entire contraction reduce blood flow and oxygenation to the fetus. Chest breathing is not effective since it doesn't increase abdominal pressure to assist the uterus to contract. Panting and blowing are used to abstain from pushing, which is not what is needed to expel the fetus. During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern? a) Moderate amount of dark red lochia drainage on peripad b) Uterine fundus palpated to the right of the umbilicus c) An oral temperature reading of 100.6°F d) Perineal area bruised and edematous beneath her ice pack - The correct response is B. A full bladder causes displacement of the uterus above it, and increased bleeding results secondary to the uncontracted status of the uterus. Massaging the uterus will help to make it firm but will not help to bring it back into the midline, since the full bladder is occupying the space the uterus would normally assume. Notifying the primary health care provider is not necessary unless the woman continues to have difficulty voiding and the uterus remains displaced. The normal location of the uterus in the fourth stage of labor is in the midline. Displacement suggests a full bladder, which is not considered a normal finding.