A nurse is assessing a client who is at 38 weeks of gestation. Upon admission 2 hr ago the client had irregular contractions, was dilated 2 cm, and was at -1 cm station. Which of the following findings indicates progression in labor?
The client reports urinary frequency.
The client has increased blood-tinged vaginal mucus.
The client's station is at 3 cm.
The client's contractions ease with walking
The Correct Answer is B
A. Urinary frequency is common in pregnancy but does not indicate labor progression.
B. Increased blood-tinged vaginal mucus (bloody show) indicates cervical dilation and labor progression.
C. Station is measured in centimeters but ranges from -3 to +3 relative to the ischial spines, so "3 cm" station is unclear and likely incorrect terminology.
D. Contractions easing with walking suggest false labor rather than progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. IV fluids should be administered cautiously in preeclampsia to avoid fluid overload; an IV bolus is not routinely indicated.
B. Monitoring for clonus is important, as it is a sign of increased neuromuscular irritability and risk of seizure in preeclampsia.
C. Misoprostol is used to manage postpartum bleeding but is not specific to preeclampsia management.
D. Fluid restriction is generally not recommended unless there are signs of fluid overload or other complications.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}
Explanation
- Administer an iron supplement: The client has low hemoglobin, hematocrit, RBCs, and ferritin, which are consistent with iron deficiency anemia. Iron supplementation is expected to help correct the deficiency and improve oxygen-carrying capacity.
- Refer for a nutritional consult: A vegan diet, if not properly planned, can lack adequate sources of iron and vitamin B12. A nutritionist can help the client meet dietary needs through fortified foods or supplements, addressing underlying causes of anemia.
- Place the client on a low sodium diet: The client’s blood pressure is within acceptable range, and there is no history of hypertension or fluid overload. A low sodium diet would not target the client’s current symptoms of anemia and fatigue.
- Restrict fluid intake: The client shows signs of volume depletion (orthostatic hypotension and low Hct) rather than fluid overload. Restricting fluids could worsen hypotension and contribute to decreased perfusion, making it inappropriate.
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