A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

The fetal head is in the left occiput posterior position.

The largest fetal diameter has passed through the pelvic outlet.

The posterior fontanel is palpable.

The lowermost portion of the fetus is at the level of the ischial spines.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.

Choice B rationale:

The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.

Choice C rationale:

The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.

Choice D rationale:

This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.

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Correct Answer is A

Explanation

Choice A rationale:

The client is experiencing continuous abdominal pain and vaginal bleeding, which are key signs of abruptio placentae. This condition occurs when the placenta prematurely separates from the uterine wall before the baby is born, leading to bleeding and potential fetal distress. The history of cocaine use can be a risk factor for abruptio placentae, as cocaine use may lead to vasoconstriction and reduced blood flow to the placenta.

Choice B rationale:

Hydatidiform mole is not likely in this case because it presents with symptoms such as vaginal bleeding and a "grape-like” mass on ultrasound. The continuous abdominal pain is not typical for a hydatidiform mole.

Choice C rationale:

Preterm labor is not the likely complication in this scenario because the client is at 38 weeks of gestation, which is considered full term. Preterm labor refers to labor that occurs before 37 weeks of gestation.

Choice D rationale:

Placenta previa is not the likely complication as it presents with painless vaginal bleeding in the third trimester, and the abdominal pain described in the question suggests a different condition.

A. Both breasts have many nodules in the upper outer quadrants. B. The client states she has bilateral breast tenderness with palpation. C. The left breast is slightly larger than the right breast. D. An irregularly shaped, nontender lump is palpable in the right breast.

Correct Answer is D

Explanation

Choice A rationale:

Having many nodules in the upper outer quadrants of the breasts is a common and expected finding in breast tissue and is not necessarily a cause for concern.

Choice B rationale:

Bilateral breast tenderness with palpation can be a normal finding, especially in young women with hormonal changes. It is not of immediate concern unless it is accompanied by other worrisome symptoms.

Choice C rationale:

Slight differences in breast size are often normal and not necessarily concerning, especially in young women whose breast development may not have fully stabilized.

Choice D rationale:

An irregularly shaped, nontender lump palpable in the breast raises concerns for a potential breast mass or tumor. This finding requires further evaluation and investigation by a healthcare provider to determine its nature and possible malignancy. Early detection of breast abnormalities is crucial for timely management and improved outcomes.

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A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?

Correct Answer is A

Explanation

During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?

Correct Answer is D

Explanation

A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?

A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

A nurse is assessing a client who gave birth 12 hr ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

True or False. For breast engorgement, do fresh cabbage leaves placed inside the bra can help alleviate pain associated with breast engorgement?