A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

"You can miss your period for several other reasons. Describe your typical menstrual cycle

"If you have been sexually active and haven't used protection it is likely that you are pregnant

"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?

"Because you have missed your period, you should try taking a home pregnancy test before you start worrying

Answer and Explanation

The Correct Answer is A

Choice A Reason:

"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.

Choice B Reason:

"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.

Choice C Reason:

"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.

Choice D Reason:

"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.

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Correct Answer is ["{"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}"]

Explanation

A. Apply oxygen at 10 L/min via venturi mask:
Anticipated: Applying oxygen is an appropriate action, especially during labor, to ensure adequate oxygenation for both the mother and the fetus.

B. Increase the oxytocin infusion to 13 mu/min:
Anticipated: Adjusting the oxytocin infusion rate may be considered based on the progress of labor and the response to the current infusion rate. This action is anticipated but should be done cautiously and in accordance with established protocols.

C. Initiate a bolus of primary IV fluids:
Anticipated: Initiating a bolus of primary IV fluids is appropriate, especially if there are signs of dehydration or if additional hydration is needed during labor.

D. Perform a sterile vaginal examination (SVE):
Anticipated: Performing a sterile vaginal examination is appropriate to assess cervical dilation, effacement, and station. This information helps in monitoring the progress of labor and making decisions about interventions.

E. Place the client in a side-lying position:
Anticipated: Placing the client in a side-lying position is an appropriate action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.

A. Contractions that last 45 seconds each with a 3 min rest between contractions B. Contractions that last for 60 seconds each with a 3-min rest between contractions C. Contractions that last for 60 seconds each with a 4-min rest between contractions D. A contraction that lasts 4 min followed by a period of relaxation

Correct Answer is B

Explanation

A. Contractions that last 45 seconds each with a 3-minute rest between contractions are less common. Typically, contractions last around 60 seconds during active labor.

B. Contractions that last for 60 seconds each with a 3-min rest between contractions is the expected pattern.

During active labor, contractions are commonly around 60 seconds in duration, and they occur approximately every 4-5 minutes.

C. Contractions that last for 60 seconds each with a 4-min rest between contractions are not consistent with the usual pattern of contractions in active labor. A 4-minute rest between contractions would be an extended interval.

D. A contraction that lasts for 4 minutes followed by a period of relaxation is not typical and may indicate a problem. Normal contractions usually last around 60 seconds or less.

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A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 42 weeks of gestation Exhibits Based on the assessment findings, which of the following actions should the nurse plan to take? (Select All that Apply)

Correct Answer is ["{"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}"]

Explanation

A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

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A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply)