A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

Observe for the presence of a nuchal cord.

Prepare to administer oxytocin.

Observe for crowning.

Apply fundal pressure.

Answer and Explanation

The Correct Answer is C

A.   Observe for the presence of a nuchal cord: While this is important, it is not specifically related to the finding of the fetal head at a certain station.
B.   Prepare to administer oxytocin: Oxytocin is a hormone used to induce or augment labor, but there is no indication for its use based solely on the fetal head station.
C.   Observe for crowning: The fetal head at 3+ station indicates significant descent, and crowning may occur soon. Crowning is the appearance of the fetal head at the vaginal opening and indicates that delivery is imminent.
D.   Apply fundal pressure: Fundal pressure is not appropriate at this stage of labor and could cause harm.

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Correct Answer is B

Explanation

Choice A: Leukorrhea, which refers to an increase in vaginal discharge, is a common discomfort during pregnancy and is generally not a cause for concern.

Choice B: Painful and tender areas on the leg may be a sign of deep vein thrombosis (DVT), a potentially dangerous condition. During pregnancy, there is an increased risk of developing blood clots, and DVT can be a serious complication that requires immediate medical attention.

Choice C: Nausea and vomiting are common in early pregnancy and are usually associated with morning sickness. While it can be uncomfortable, it is generally not considered a dangerous symptom unless it leads to severe dehydration.

Choice D: Urinary frequency is a common discomfort during pregnancy, especially in the first and third trimesters. Although it can be bothersome, it is not typically a sign of immediate danger.

A. Fetal position is persistent occiput posterior. B. Fetal attitude is in general flexion. C. Fetal lie is longitudinal D. Maternal pelvis is gynecold.

Correct Answer is A

Explanation

A. Fetal position is persistent occiput posterior: The occiput posterior position (the back of

the baby's head facing the mother's back) can lead to a more challenging and prolonged labor with intense back pain.
B. Fetal attitude is in general flexion: Flexion is the normal fetal attitude for birth and does not contribute to a difficult labor with backache.
C. Fetal lie is longitudinal: Longitudinal lie refers to the baby's position along the mother's spine, but it doesn't specify the position of the baby's back, so it is not directly related to backache.
D. Maternal pelvis is gynecoid: Gynecoid pelvis is the most favorable pelvis shape for childbirth, so it is not likely to cause difficult labor with severe backache.

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A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

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Correct Answer is B

Explanation

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

Correct Answer is A

Explanation

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