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?

Shoulder

Mentum

Breech

Vertex

Answer and Explanation

The Correct Answer is D

Choice D: Leopold maneuvers are used to determine the fetal position and presentation by palpating the abdomen. ROA stands for Right Occiput Anterior, which means the baby's head is presenting and facing towards the mother's right side (Occiput) and positioned anteriorly (front of the pelvis).

This position is a common and favorable presentation for a vaginal delivery.

Choice A: Shoulder presentation is when the baby is presenting with the shoulder rather than the head. It is an abnormal presentation and requires a cesarean delivery.

Choice B: Mentum presentation is a type of face presentation, where the baby's chin (mentum) is presenting instead of the head. It is also an abnormal presentation and usually requires a cesarean delivery.

Choice C: Breech presentation is when the baby's buttocks or feet are presenting first instead of the head. It is another abnormal presentation that may require a cesarean delivery or careful vaginal delivery with a skilled healthcare provider.

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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.

A. "A gain of about 1 pound per week is the best pattern for you." B. "It would be best if you gained about 11 to 20 pounds." C. "The recommendation for you is about 15 to 25 pounds." D. "A gain of about 25 to 35 pounds is recommended for you."

Correct Answer is C

Explanation

Choice A: A weight gain of about 1 pound per week is a general guideline for women with normal BMI. However, for a client with a BMI of 26.5, the recommended weight gain during pregnancy may differ.
Choice B: Gaining 11 to 20 pounds may not be sufficient for a client with a BMI of 26.5, as the recommended weight gain is slightly higher for women with a higher prepregnancy BMI.

Choice C: For a client with a BMI of 26.5, the recommended weight gain during pregnancy is approximately 15 to 25 pounds. This range is specific to women with a BMI in the overweight category.
Choice D: Gaining 25 to 35 pounds is recommended for clients with a lower BMI range (normal BMI). For a client with a BMI of 26.5, this amount of weight gain may be excessive.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who is a primigravida, at term, and having contractions. The client states that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as the most reliable sign of true labor?

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

A nurse is providing dietary education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

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?