A nurse is caring for a client who has been in labor for 12 hours with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy?
Fetal position
Fetal lie
Fetal attitude
fetal engagement
The Correct Answer is D
The correct answer is D. Fetal engagement
A. Fetal position, fetal lie, and fetal attitude are important aspects of the fetal presentation but are not specific considerations when performing an amniotomy.
B. Fetal lie is the relationship between the long axis of the fetus and the long axis of the mother. It is not directly relevant to the consideration of amniotomy.
C. Fetal attitude refers to the relationship of the fetal body parts to each other. It is not a specific consideration for amniotomy.
D. Fetal engagement is the correct consideration prior to amniotomy.
Fetal engagement refers to the descent of the fetal presenting part into the pelvis. Before performing an amniotomy, it is important to confirm that the fetal head is engaged in the pelvis, ensuring a lower risk of cord prolapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The pattern of contractions is important in assessing labor, but the presence of regular contractions alone does not confirm true labor. It is the changes in the cervix that indicate progress in labor.
B. The station of the presenting part (the level at which the baby's head has descended into the pelvis) is also a factor in labor, but it is not the primary indicator of true labor. Changes in the cervix are more indicative.
C. Changes in the cervix are a key sign of true labor.
True labor involves cervical effacement (thinning) and dilation (opening). These changes in the cervix signify progress in the labor process.
D. Rupture of the membranes (water breaking) can be a sign of labor, but it doesn't confirm true labor on its own. It might occur before, during, or after labor has begun.
Correct Answer is D
Explanation
Choice A Reason:
Hct 39.6 is incorrect. This hemoglobin level is within a typical range and may not require immediate intervention.
Choice B Reason:
Serum albumin 4.5 g/dL is incorrect. A serum albumin level of 4.5 g/dL is within the normal range and does not suggest an urgent issue.
Choice C Reason:
WBC 9,000/mm³ is incorrect. A white blood cell count of 9,000/mm³ is within the normal range and is not typically a cause for immediate concern in the absence of other symptoms or indications.
Choice D Reason:
Platelets 50,000/mm³ is correct. A platelet count of 50,000/mm³ is significantly below the normal range and may indicate thrombocytopenia, a condition associated with preeclampsi
A. Thrombocytopenia in preeclampsia can lead to bleeding complications and requires close monitoring and management.
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