A 28-year-old female client is in the second stage of labor in the maternity ward.

Exhibits

A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.

Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.

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Correct Answer is B

Explanation

Choice A rationale
A baseline BP of 140/85 mmHg is considered high, but a current BP of 129/80 mmHg is within the normal range. Therefore, this would not typically indicate a risk for pregnancy-induced hypertension.
Choice B rationale
A significant increase in blood pressure from a baseline of 110/70 mmHg to a current BP of 145/85 mmHg could indicate a risk for pregnancy-induced hypertension.
Choice C rationale
A slight increase in blood pressure from a baseline of 120/80 mmHg to a current BP of 126/85 mmHg would not typically indicate a risk for pregnancy-induced hypertension.
Choice D rationale
An increase in blood pressure from a baseline of 110/60 mmHg to a current BP of 120/63 mmHg would not typically indicate a risk for pregnancy-induced hypertension.

A. Vaginal discharge B. Elevated blood pressure C. Joint pain D. Increased urine output

Correct Answer is B

Explanation

Choice A rationale
Vaginal discharge is common during pregnancy due to the increased production of estrogen and greater blood flow to the pelvic area. It is not typically a sign of preeclampsia.
Choice B rationale
Elevated blood pressure is a primary symptom of preeclampsia. If a pregnant client has high blood pressure, it should indicate to the nurse that the client requires further evaluation for this disorder.
Choice C rationale
Joint pain is not typically a symptom of preeclampsia. It could be related to other conditions or simply a result of the physical changes of pregnancy.
Choice D rationale
Increased urine output is not typically associated with preeclampsia. In fact, decreased urine output could potentially be a sign of kidney problems related to preeclampsia.

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Naxlex Comprehensive Predictor Exams

Which blood pressure (BP) finding during the second trimester indicates a risk for pregnancy-induced hypertension?

Correct Answer is B

Explanation

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Correct Answer is B

Explanation

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. Which of the following newborn complications should the nurse recognize as the priority focus of care?

A nurse in a prenatal clinic is caring for a pregnant client who inquires about her estimated date of birth (EDB). If the client’s last menstrual period started on July 27, what would be the client’s EDB? (Provide the date in MMDD format. For example, July 27 is 0727) .

A nurse in labor and delivery is caring for a client. Following the delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

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A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

A nurse is caring for a patient who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. What would be an appropriate nursing action in this situation?