A nurse is examining a client who is in active labor and observes that the presenting part is in the left occiput posterior position.
What is the clinical interpretation of this finding?
The posterior fontanel is palpable.
The lowermost portion of the fetus is at the level of the ischial spines.
The largest fetal diameter has passed through the pelvic outlet.
The fetal head is in the left occiput posterior position.
The Correct Answer is D
Choice A rationale
The palpability of the posterior fontanel is not related to the position of the fetus.
Choice B rationale
The level of the ischial spines refers to the station of the fetus, not its position.
Choice C rationale
The passage of the largest fetal diameter through the pelvic outlet is a stage of labor, not a fetal position.
Choice D rationale
This is the correct answer. The left occiput posterior position refers to the position of the fetal head.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering oxygen via a nasal cannula is not the appropriate response to a client experiencing tingling fingers during pattern-paced breathing. This symptom is not indicative of hypoxia.
Choice B rationale
Having the client tuck her chin to her chest can help alleviate the tingling sensation. This position can help reduce hyperventilation, which is often the cause of the tingling.
Choice C rationale
Assisting the client to breathe into a paper bag is not the appropriate response to a client experiencing tingling fingers during pattern-paced breathing. This action is typically used to treat hyperventilation, but it is not the first-line intervention.
Choice D rationale
Instructing the client to increase her respiratory rate to more than 42 breaths per minute is not the appropriate response to a client experiencing tingling fingers during pattern-paced breathing. This could exacerbate the problem by causing further hyperventilation.
Correct Answer is A
Explanation
Choice A rationale
Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy. This allows the nurse to monitor for signs of fetal distress, which can occur if the umbilical cord becomes compressed or prolapses as a result of the procedure.
Choice B rationale
Observing the color and consistency of the fluid can provide information about the well-being of the fetus, but it is not the priority action following an amniotomy.
Choice C rationale
Assessing the client’s temperature is important to monitor for signs of infection, but it is not the priority action following an amniotomy.
Choice D rationale
Evaluating the client for the presence of chills and increased uterine tenderness using palpation can help identify complications such as infection or uterine rupture, but it is not the priority action following an amniotomy.
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