The nurse has determined through digital exam that the client's cervix is 8 cm dilated. The client has a slight urge to push.
The nurse should encourage the mother to not bear down until after the cervix is completely dilated to prevent: (Select all that apply.) A. Maternal exhaustion.
B. Cervical edema.
C. Tearing and bruising of the cervix.
D. Enhanced perineal thinning.
E. Lack of pain control.
Question 2
Four minutes after the birth of a client's baby, there is a sudden gush of blood from the client's vagina and about eight inches of umbilical cord slides out of her vagina. What action should the nurse take first?
A. Place the bed in Trendelenberg position.
B. Watch for the emergence of the placenta.
C. Prepare for the delivery of an undiagnosed twin.
D. Roll her onto her left side.
An ear exam, or otoscopy, using an otoscope.
Pulse oximetry. The small device provides a digital readout of oxygen levels in the blood.
Portable digital refractometer.
Using small, circular strokes, exfoliate the client’s neck and back.
Removing the sheet from underneath the client.
Testing client’s ability to identify sharp sensations