A 32-year-old woman is dilated 4 cm. The health care provider states that she has a roomy pelvis and the baby is in a right occiput anterior (ROA) position at +1 station. Her contractions are occurring every 10 minutes, lasting 30 to 40 seconds, and palpate mild in intensity. She is calm and relaxed. Given these data, which essential component of labor is unexpected and likely to slow the progress of labor at this time?
Passageway
Powers
Psyche
Passenger
The Correct Answer is B
A. Passageway – Incorrect; the provider states she has a roomy pelvis, meaning the passageway is adequate.
B. Powers – Correct; contractions are infrequent (every 10 minutes), short (30-40 sec), and mild, which may not be strong enough to promote cervical dilation and descent of the fetus.
C. Psyche – Incorrect; the patient is calm and relaxed, which supports labor progression.
D. Passenger – Incorrect; the baby is in an optimal (ROA) position and at +1 station, indicating normal progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "You will need to discuss this with the provider." – Incorrect; the nurse plays a key role in assessing and incorporating cultural practices into care.
B. "There are specific pain management options that you need to use." – Incorrect; this does not consider the client’s preferences and cultural beliefs.
C. "It is better to use pain management options that have been researched." – Incorrect; while evidence-based practices are important, cultural preferences should be respected.
D. "We will work with you to incorporate the practices that are safe for you and your fetus." – Correct; this response is client-centered and respects cultural beliefs while ensuring safety.
Correct Answer is C
Explanation
A. Feel for a full bladder. – Incorrect; a full bladder can contribute to postpartum bleeding, but checking fundal firmness should be prioritized first.
B. Request the provider perform a vaginal examination. – Incorrect; the nurse should assess the fundus and attempt interventions first before calling the provider.
C. Check the client’s fundus. – Correct; the priority action is to assess the fundus for firmness, as a boggy uterus is the most common cause of postpartum hemorrhage.
D. Measure the client’s vital signs. – Incorrect; while vital signs are important, assessing fundal tone and initiating interventions come first.
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