A nurse is providing care to a client in labor.

A pelvic exam reveals a vertex presentation with the presenting part tilted toward the left side of the mother's pelvis and directed toward the anterior portion of the pelvis.

When developing this client's plan of care, which intervention would the nurse include?

Implementing measures for a vaginal birth.

Instituting continuous internal fetal monitoring.

Assisting with artificial rupture of the membranes.

Preparing the client for a cesarean birth.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Implementing measures for a vaginal birth is a reasonable intervention as the baby is in a favorable position for a normal delivery.

Choice B rationale:

Continuous internal fetal monitoring is not necessary unless there are complications or high-risk factors present.

Choice C rationale:

Artificial rupture of the membranes can be done to induce or augment labor, but it’s not necessary in this case.

Choice D rationale:

Preparing for a cesarean birth is not necessary as the baby is in a favorable position for a vaginal birth.

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Correct Answer is D

Explanation

Choice A rationale:

Notifying the primary care provider is important but not the immediate next step. The nurse has other immediate responsibilities to ensure the safety of the mother and baby.

Choice B rationale:

A vaginal exam could introduce bacteria into the uterus and is not the immediate next step after rupture of membranes.

Choice C rationale:

Changing the linen saver pad is not the immediate next step. While it might be necessary for the comfort of the mother, it does not address the potential risks associated with rupture of membranes.

Choice D rationale:

Checking the fetal heart rate is the correct next step. This ensures that the baby is not in distress following the rupture of membranes.

A. Butorphanol. B. Promethazine. C. Fentanyl. D. Naloxone.

Correct Answer is D

Explanation

Answer and explanation

Choice A rationale:

Butorphanol is an opioid agonist-antagonist. It would not be the first choice to treat opioid-induced respiratory depression because it can also cause respiratory depression.

Choice B rationale:

Promethazine is an antihistamine that has sedative effects and could potentially worsen respiratory depression.

Choice C rationale:

Fentanyl is a potent opioid and would likely exacerbate respiratory depression.

Choice D rationale:

Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Correct Answer is D

Explanation

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?.

Correct Answer is D

Explanation

A pregnant woman is diagnosed with iron deficiency anemia and is prescribed an iron supplement. After teaching her about her prescribed iron supplement, which statement indicates successful teaching?.

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as

A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction?.

After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first:.

During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate?.

The nurse is counseling a couple who suspect that they could bear a child with a genetic abnormality. What would be most important for the nurse to do when working with this family?.