A nurse is assisting with the care of a client who is multigravid and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriate nursing response?

Help the client to the bathroom to empty her bladder.

Assist the client into a comfortable position.

Have the client pant during the next few contractions.

Assess the perineum for signs of crowning.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labour, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.

Choice B rationale:

Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.

Choice C rationale:

Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labour has commenced. Panting is not necessary at this point.

Choice D rationale:

The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.

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Correct Answer is C

Explanation

Choice C rationale:

This response is correct because black stools are a common side effect of taking iron supplements. Iron can cause the stool to appear black or

tarry due to the way it is broken down during digestion. It does not necessarily indicate a serious issue, especially if the client is not experiencing any abdominal pain or cramping. Educating the client about this expected side effect helps alleviate any concerns they might have about the change in stool colour.

Choice A rationale:

"Go to the emergency room and your provider will meet you there.”. This response is not appropriate in this situation. The client's report of black stools without abdominal pain or cramping is likely due to the iron supplements and does not warrant a visit to the emergency room. This response may cause unnecessary panic and anxiety for the client.

Choice B rationale:

"What else have you been eating?.”. This response is also not the best choice. While it's essential for healthcare providers to gather comprehensive information about a client's diet and lifestyle, in this case, the client's black stools can be directly attributed to the iron supplements. Focusing on other dietary factors might distract from addressing the client's concern about the side effect of iron supplementation.

Choice D rationale:

"Come to the office, and we will check things out.”. This response is not the most appropriate one either. A visit to the office might not be necessary solely based on the client's report of black stools without accompanying pain or cramping. This situation can be managed through education, and the client can be reassured that it is a typical side effect of iron supplements. An unnecessary visit to the office could inconvenience the client and waste both their time and the healthcare provider's time.

A. Abdominal pain with minimal red vaginal bleeding. B. A large amount of bright red vaginal bleeding without pain. C. Severe abdominal pain with increasing fundal height. D. Intermittent abdominal pain following the passage of bloody mucus.

Correct Answer is B

Explanation

Choice A rationale:

Abdominal pain with minimal red vaginal bleeding may not be as concerning as other options. While it could be a sign of placenta previa, it is not as specific or significant as the finding in Choice B.

Choice B rationale:

A large amount of bright red vaginal bleeding without pain is a significant finding that is highly suggestive of placenta previa. Placenta previa occurs when the placenta partially or completely covers the cervix, and vaginal bleeding is a common symptom. The bright red colour indicates active bleeding, and the absence of pain is noteworthy as placenta previa bleeding is typically painless.

Choice C rationale:

Severe abdominal pain with increasing fundal height is not a typical sign of placenta previa. While abdominal pain can be associated with various pregnancy complications, it is not a specific finding for this condition.

Choice D rationale:

Intermittent abdominal pain following the passage of bloody mucus could be related to other issues, such as preterm labor or cervical changes. While bleeding may be present in placenta previa, the pain and passage of mucus are not characteristic features of this condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is speaking on the phone to a client who is pregnant and taking iron supplements for iron-deficiency anaemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?

Correct Answer is B

Explanation

A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?