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 C

Explanation

The correct answer is C. Observe for crowning.

A. Applying fundal pressure is not indicated when the fetal head is at 3+ station. Fundal pressure is generally discouraged as it can increase the risk of fetal and maternal complications.

B. Preparing to administer oxytocin may be necessary later in labor but is not the immediate priority when the fetal head is still at 3+ station.

C. Observing for crowning is the correct action.

Crowning occurs when the widest part of the fetal head is visible at the vaginal opening during contractions. It is a sign that the baby is descending and the client is in the second stage of labor.

D. Observing for the presence of a nuchal cord is a valid consideration, but observing for crowning takes precedence at this stage of labor. Nuchal cords can be managed appropriately once the fetal head has descended further.

A. Have the client void. B. Position the client with one hip elevated. C. Ask the client if she needs pain medication. D. Notify the provider of the findings.

Correct Answer is B

Explanation

The correct answer is B. Position the client with one hip elevated.

A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.

B. Positioning the client with one hip elevated is the priority action.

The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.

C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.

D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.

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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 gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an Indication for fetal assessment using electronic fetal monitoring?

A nurse is caring for a client who was in the first stage of labor and is encouraging the client to void every two hours. Which of the following statements should the nurse make?

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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?

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A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make to the client?