A nurse is admitting a client who is at 38 weeks of gestation and is in the active phase of the first stage of labor. Which of the following assessment findings is the first priority for the nurse to report to the provider?

Contractions lasting 2 minutes and with no rest between contractions.

Pressure on the perineum causing the client to have the desire to bear down.

Discharge consisting of clear fluid from the vagina.

Passage of a bloodtinged mucous plug.

Answer and Explanation

The Correct Answer is A

Choice A: The first priority assessment finding to report to the provider is contractions lasting 2 minutes and with no rest between contractions. Prolonged contractions without adequate rest can lead to uterine hyperstimulation and fetal distress, potentially compromising the wellbeing of both the client and the baby. The provider needs to be informed immediately for further

evaluation and intervention.

Choice B: Pressure on the perineum and the desire to bear down indicate that the client is experiencing the urge to push, which is expected during the second stage of labor, not during the active phase of the first stage. It is not the first priority to report.

Choice C: Clear fluid discharge from the vagina can indicate rupture of membranes, but it is not an immediate concern unless the fluid is meconiumstained or there are other signs of fetal distress.

Choice D: Passage of a bloodtinged mucous plug (also known as "bloody show") is a common sign that labor is approaching, but it is not an immediate concern unless there are other signs of labor progression or complications. It is not the first priority to report.

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Correct Answer is C

Explanation

A. The client requires a rubella vaccination at this time. This is incorrect because rubella vaccination is contraindicated during pregnancy due to the risk of congenital rubella syndrome. Vaccination should be administered postpartum.

B. The client is not experiencing a rubella infection at this time. While this statement is true, it does not address the need for future immunization, which is the critical aspect of the interpretation.

C. The client requires a rubella immunization following delivery. This is correct because a negative rubella titer indicates that the client is not immune to rubella and should receive the vaccine postpartum to prevent future infection.

D. The client is immune to the rubella virus. This is incorrect because a negative rubella titer indicates a lack of immunity to rubella, meaning the client is susceptible to infection.

A. "You should take a deep, cleansing breath and breathe naturally." B. "You should go ahead and push as hard as you can to assist the delivery." C. "You should try to blow or pant as the baby is being born to help avoid a toorapid birth." D. "You should try to perform slowpaced breathing patterns."

Correct Answer is C

Explanation

A: Taking deep, cleansing breaths and breathing naturally is not the appropriate technique during the crowning phase of labor, as it can increase the risk of rapid birth and potential perineal trauma.

C: During a precipitous labor with the baby's head crowning, the nurse should encourage the mother to perform blowing or panting breaths during contractions. This technique helps to slow down the delivery process and allows the perineum to stretch gradually, reducing the risk of tearing or other trauma.

B: In the case of precipitous labor, actively pushing as hard as possible can increase the risk of rapid birth and potential complications for both the mother and the baby.

D: Slowpaced breathing patterns are not recommended during the crowning phase of labor, as they may not effectively control the birth process.

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A nurse is admitting a client who is at 38 weeks of gestation and is in the active phase of the first stage of labor. Which of the following assessment findings is the first priority for the nurse to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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