A nurse is caring for a client who is in active labor and has just been examined as being at 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

"Assist the client into a more comfortable position."

"Observe the perineum for signs of crowning."

"Have the client pant or blow during the next contractions to help her refrain from pushing."

"Help the client to the bathroom to empty her bladder."

Answer and Explanation

The Correct Answer is B

Choice A: At 7 cm dilation, the client is in active labor, and assisting her into a more comfortable position may not be appropriate at this stage. It is essential to observe for signs of impending birth and assess the progress of labor.

Choice B: Feeling the urge to push may indicate that the baby is descending and the cervix is fully dilated. The nurse should immediately observe the perineum for signs of crowning (when the baby's head starts to appear at the vaginal opening) to prepare for delivery.

Choice C: If the client is feeling the urge to push and the cervix is fully dilated, panting or blowing through contractions will not be effective. It is important to allow the client to follow her body's natural urges to push.

Choice D: While emptying the bladder is generally recommended during labor to provide more room for the baby to descend, the client's current urge to push suggests that the baby is likely in a lower position, and it might not be safe or feasible to move the client to the bathroom.

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Correct Answer is D

Explanation

A. "The test will be performed if your baby's heartbeat is heard."
Incorrect: Amniocentesis is not typically performed based on whether the baby's heartbeat is heard. It is done for specific diagnostic purposes, such as genetic testing or assessing certain fetal conditions.

B. "This test will determine if your baby's lungs are mature."
Incorrect: Amniocentesis does not determine fetal lung maturity. The test involves the extraction of a small amount of amniotic fluid to analyze fetal chromosomes and identify genetic conditions.

C. "After the test, you will be given Rh immune globulin since you are Rh positive."
Incorrect: Rh immune globulin (Rhogam) is given to Rhnegative pregnant women to prevent Rh sensitization, which occurs when an Rhnegative mother is exposed to
Rhpositive fetal blood. Rhogam is not directly related to amniocentesis.

D. "This test requires the presence of an adequate volume of amniotic fluid."
Correct: Amniocentesis requires a sufficient amount of amniotic fluid around the fetus for safe and accurate testing. If there is not enough amniotic fluid, the procedure may be postponed or canceled.

A. Variable decelerations B. Late decelerations C. Accelerations D. Early decelerations

Correct Answer is A

Explanation

Choice A: Variable decelerations on the fetal heart rate monitor tracing are suggestive of umbilical cord compression. These decelerations are often V, U, or Wshaped, and their onset, depth, and duration can vary. They are associated with cord compression, which can reduce blood flow to the fetus during contractions. Other options are as follows:

Choice B: Late decelerations are indicative of uteroplacental insufficiency and are not related to umbilical cord problems.

Choice C: Accelerations are reassuring and suggest a responsive, healthy fetus.

Choice D: Early decelerations are usually benign and result from head compression during contractions, not umbilical cord issues.

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Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

Correct Answer is D

Explanation

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when he observes which of the following patterns?

Correct Answer is A

Explanation

A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who is in the first stage of labor and is using patternpaced breathing. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

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?

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 on the labor and delivery unit is caring for a client following a vaginal examination by the provider, which is documented as: 1. Which of the following interpretations of this finding should the nurse make?

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

A nurse in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?