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

Choice A: While relaxation can be helpful during a pelvic examination, it is not the most comprehensive response to address the client's concerns.

Choice B: A pelvic examination is not always required for prescribing birth control pills. In many cases, a healthcare provider can prescribe oral contraceptives based on the client's medical history and other factors without a pelvic exam.

Choice C: This response encourages the client to express her specific concerns and fears related to the examination, allowing the nurse to address them directly and provide appropriate support and reassurance.

Choice D: Although offering support during the exam is important, it does not address the client's nervousness and concerns about the examination itself.

A. Turn the client onto her side. B. Increase the client's IV fluid infusion rate. C. Administer oxygen to the client. D. Palpate the client's uterus.

Correct Answer is A

Explanation

Choice A:The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
Choice B: Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
Choice C: Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
Choice D: Palpating the client's uterus is not the first priority in the presence of late

decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.

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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 in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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