Author Question: The nurse examines a primipara's cervix at 8-9/100/+2; it is tight against the fetal head. The ... (Read 35 times)

nelaaney · **on:** Jun 28, 2018

The nurse examines a primipara's cervix at 8-9/100/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurse's priority action?

a. Palpate her bladder for fullness.
b. Assess the frequency and duration of her contractions.
c. Determine who will stay with the patient for the birth.
d. Encourage the patient to exhale in short breaths with contractions.

Question 2

The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter?

a. Place the catheter as quickly as possible.
b. Place a small pillow under the patient's left hip.
c. Omit the use of a cleansing agent, such as Betadine.
d. Set up the catheter tray before positioning the patient.

mistyjohnson · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patient's urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push.

Answer to Question 2

ANS: B
To promote placental function, the nurse can place a small pillow or rolled blanket under the patient's left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care.