A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

"Maybe next time you can have a vaginal delivery."

"It sounds like you are feeling sad that things didn't go as planned."

"You can resume sexual relations sooner than if you had delivered vaginally."

"At least you know you have a healthy baby."

Answer and Explanation

The Correct Answer is B

A)   "Maybe next time you can have a vaginal delivery.": This response may not be appropriate as it assumes a future pregnancy and vaginal delivery is guaranteed. It may not address the client's current feelings of disappointment adequately.
B)   "It sounds like you are feeling sad that things didn't go as planned.": This is the correct answer as it shows empathy and validates the client's feelings of disappointment. It acknowledges the client's emotions and provides support during this sensitive time.

C)   "You can resume sexual relations sooner than if you had delivered vaginally.": While this statement may be true, it is not directly related to the client's expressed feelings of disappointment.
D)   "At least you know you have a healthy baby.": This response dismisses the client's feelings and may not be wellreceived, as the client is expressing a desire for emotional support rather
than a reassurance about the baby's health.

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Correct Answer is A

Explanation

Choice A: After an amniotomy (artificial rupture of membranes), the priority action by the nurse is to assess the fetal heart rate. Amniotomy can lead to changes in fetal heart rate patterns, and the nurse needs to ensure that the baby's wellbeing is not compromised after the procedure.

Choice B: Providing clean, dry underpads is important for maintaining hygiene and cleanliness after the procedure but is not the priority action. The fetal heart rate assessment takes precedence.

Choice C: Assessing the odor of the amniotic fluid is essential to identify any signs of infection, but it is not the priority action immediately following the amniotomy. Fetal wellbeing is the priority.

Choice D: Monitoring the client's temperature is important for identifying any signs of infection, but it is not the priority action. Assessing the fetal heart rate is more critical at this time.

A. Temperature 38.2°C (100.8°F) B. The client reports reduced sensation of the lower extremities. C. The client reports generalized itching. D. Blood pressure 80/52 mm Hg

Correct Answer is D

Explanation

A: Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B: Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C: Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D: Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.

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A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?

Correct Answer is D

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?

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching?

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone (Cervidil) gel. Which of the following statements should the nurse include in the teaching?

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?