A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

"This always happens by the end of the first trimester of pregnancy."

"This will occur during the last trimester of pregnancy."

"This usually happens between the fourth and fifth months of pregnancy"

"This will happen once the uterus begins to rise out of the pelvis."

Answer and Explanation

The Correct Answer is C

A.   "This always happens by the end of the first trimester of pregnancy.": Quickening typically occurs later in pregnancy, not by the end of the first trimester.
B.   "This will occur during the last trimester of pregnancy.": Quickening occurs much earlier than the last trimester.
C.   "This usually happens between the fourth and fifth months of pregnancy.": Quickening, which is the first perception of fetal movements by the mother, generally occurs between 16 to 20 weeks of gestation.
D.   "This will happen once the uterus begins to rise out of the pelvis.": Quickening does not directly correlate with the rising of the uterus out of the pelvis.

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Correct Answer is D

Explanation

Leopold maneuvers are used to determine the fetal position and presentation by palpating the abdomen. ROA stands for Right Occiput Anterior, which means the baby's head is presenting and facing towards the mother's right side (Occiput) and positioned anteriorly (front of the pelvis).

This position is a common and favorable presentation for a vaginal delivery.

Choice A: Shoulder presentation is when the baby is presenting with the shoulder rather than the head. It is an abnormal presentation and requires a cesarean delivery.

Choice B: Mentum presentation is a type of face presentation, where the baby's chin (mentum) is presenting instead of the head. It is also an abnormal presentation and usually requires a cesarean delivery.

Choice C: Breech presentation is when the baby's buttocks or feet are presenting first instead of the head. It is another abnormal presentation that may require a cesarean delivery or careful vaginal delivery with a skilled healthcare provider.

A. Administer glucocorticoids intramuscularly. B. Prepare the client for emergency cesarean section. C. Assess the odor of the amniotic fluid. D. Recheck the client's temperature in 4 hr.

Correct Answer is C

Explanation

A: Administering glucocorticoids intramuscularly is indicated for enhancing fetal lung maturity in cases of anticipated preterm birth. However, the client is at 38 weeks of gestation, which is not considered preterm, and the elevated temperature is the main concern.
B: Preparing the client for an emergency cesarean section based solely on an elevated temperature is not an appropriate action. There may be other factors contributing to the temperature elevation, and further assessment is needed.

C: An elevated temperature during pregnancy can indicate infection, which is a concern when the client's membranes have ruptured (premature rupture of membranes or PROM). Before any
interventions are initiated, the nurse should assess the odor of the amniotic fluid as it can provide important information about possible infection. If the amniotic fluid has a foul odor or appears
cloudy, it may indicate infection and require prompt medical attention.

D: Rechecking the client's temperature in 4 hours is not the appropriate immediate action when an elevated temperature is observed, especially in a pregnant woman.

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A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an ROA position. Which of the following fetal presentations should the nurse document in the client's medical record?

Correct Answer is D

Explanation

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

Correct Answer is C

Explanation

A nurse is caring for a client who is 42 weeks of gestation. Based on the assessment findings, which of the following actions should the nurse plan to take? (Select all that apply.)

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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 active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

A nurse is caring for a client who is a primigravida, at term, and having contractions. The client states that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as the most reliable sign of true labor?