QUESTION: "After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which of the following?"
CHOICES
( X ) a.) Be in a semi-Fowler's position or a position of comfort.
( X ) b.) Flex her thighs onto her abdomen before bearing down.
( X ) c.) Exert downward pressure as if she were having a bowel movement.
( O ) d.) Hold her breath throughout the length of the contraction.
RATIONALE: The client should use exhale breathing (inhaling several deep breaths, holding the breath for 5 to 6 seconds, and exhaling slowly every 5 to 6 seconds through pursed lips while continuing to hold the breath) while pushing to avoid the adverse physiologic effects of the Valsalva maneuver, occurring with prolonged breath-holding during pushing. The Valsalva maneuver also can be avoided by exhaling continuously while pushing. Semi-Fowler's position enhances the effectiveness of the abdominal muscle efforts during pushing, but the client can assume a squatting or side-lying position if desired. The client should flex her thighs onto her abdomen before bearing down. The client should exert downward pressure as if she were having a bowel movement while pushing. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
