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 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.

A. All of the clients B. A client who has a history of preterm labor C. A client who has mitral valve prolapse D. A client who has been exposed to AIDS

Correct Answer is A

Explanation

A) All of the clients: Maternal serum alphafetoprotein (MSAFP) screening is a routine prenatal test offered to all pregnant women, usually between 15 and 20 weeks of gestation. It is used to screen for certain fetal anomalies, including neural tube defects such as spina bifida and anencephaly. Regardless of a client's medical history or risk factors, the MSAFP screening is typically recommended for all pregnant individuals as part of routine prenatal care.
B) A client who has a history of preterm labor: Preterm labor history is not a specific indication for MSAFP screening. This test is primarily used to screen for fetal anomalies, not preterm labor risk assessment.
C) A client who has mitral valve prolapse: Mitral valve prolapse is also not an indication for MSAFP screening. The test is focused on assessing fetal health and not maternal heart conditions.
D) A client who has been exposed to AIDS: MSAFP screening is not related to maternal exposure to AIDS. It is a test focused on assessing the fetus's risk of certain congenital abnormalities.

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Naxlex Comprehensive Predictor Exams

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 in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alphafetoprotein (MSAFP) screening for which of the following clients?

Correct Answer is A

Explanation

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

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?

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching?

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?