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 C

Explanation

A: Administering a 500 mL bolus of 5% dextrose in water is not necessary before the epidural administration, and it may not be recommended in active labor as it can increase the risk of fluid overload.

B: The duration of the anesthetic effect of the epidural can vary depending on the medication used, and it is not the nurse's priority during the preparation process.

C: Prior to administering epidural analgesia, the nurse should obtain a 30minute electronic fetal monitoring (EFM) strip to assess the fetal heart rate and monitor for any signs of fetal distress during the procedure.

D: Having the client stand very still with her arms at her side is not practical or necessary for epidural administration and could be uncomfortable for the client during labor.

A. Quickening B. Ballottement C. Chloasma D. Lightening

Correct Answer is A

Explanation

A) Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B) Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C) Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D) Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?

Correct Answer is A

Explanation

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