A nurse is caring for a client who is at 40 weeks gestation and is lying supine while in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing
interventions should the nurse perform?

Assist the client to an upright position.

Prepare for a cesarean birth.

Assist the client to turn onto her side.

Prepare for an immediate vaginal delivery.

Answer and Explanation

The Correct Answer is C

Choice A: While an upright position is generally beneficial during labor to improve uterine contractions and fetal positioning, it is not the priority in this situation of hypotension.
Choice B: Preparing for a cesarean birth is not indicated solely based on the blood pressure reading. Cesarean birth should be considered based on the overall assessment and clinical condition of the client and baby.
Choice C: The client's blood pressure reading of 82/52 mm Hg indicates hypotension. In this situation, the nurse should assist the client in turning onto her side to relieve pressure on the vena cava and improve blood flow to the placenta and the baby. Lying supine can compress the vena cava, leading to decreased venous return and reduced cardiac output, which may negatively affect fetal oxygenation and maternal wellbeing.
Choice D: Preparing for an immediate vaginal delivery is not the priority at this moment. The nurse should first address the hypotension and improve maternal blood flow before proceeding with delivery.

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Correct Answer is D

Explanation

The correct answer is: April 11, 2016

Choice A: April 27, 2016

Reason: Using Naegele’s Rule, the estimated date of delivery (EDD) is calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). For an LMP of May 4, 2015:

Add one year: May 4, 2016
Subtract three months: February 4, 2016
Add seven days: February 11, 2016

April 27, 2016, is incorrect because it does not follow the correct calculation steps.

Choice B: April 11, 2016

Reason: Following Naegele’s Rule:

Add one year: May 4, 2016
Subtract three months: February 4, 2016
Add seven days: February 11, 2016

April 11, 2016, is the correct EDD as it accurately follows the calculation steps.

Choice C: February 27, 2016

Reason: This date is incorrect because it does not follow the correct calculation steps of Naegele’s Rule. The correct EDD should be in April, not February.

Choice D: February 11, 2016

Reason: This date is also incorrect. While it follows the initial steps of Naegele’s Rule, it does not account for the full calculation, which should result in an April date, not February.

A. "This will determine if there is more than one fetus." B. "It assists in identifying the location of the placenta and fetus." C. "This is a screening tool for spina bifida." D. "It is useful for estimating fetal age."

Correct Answer is B

Explanation

Choice A: An ultrasound can indeed determine the number of fetuses if a client is carrying multiples, but this is not the primary reason for performing an ultrasound before amniocentesis.

Choice B: An ultrasound is typically done before an amniocentesis to visualize the location of the placenta and fetus. This information is important to ensure that the amniocentesis needle is safely inserted away from the placenta and the fetus.

Choice C: The primary purpose of an amniocentesis is to obtain a sample of amniotic fluid to screen for genetic conditions, not specifically for spina bifida.

Choice D: Fetal age can be estimated through an ultrasound, but this is not the primary reason for performing an ultrasound before an amniocentesis. The main goal of the procedure is to obtain a sample of amniotic fluid for genetic testing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. The nurse uses Naegele's Rule to calculate the correct EDD:

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

A nurse is admitting a client who is at 38 weeks of gestation and is in the active phase of the first stage of labor. Which of the following assessment findings is the first priority for the nurse to report to the provider?

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

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?