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 A

Explanation

Choice A rationale:

This statement is incorrect. While continuous internal electronic fetal monitoring does limit mobility, it doesn’t require the woman to stay completely still.

Choice B rationale:

This is correct. An electrode may be inserted into the baby’s scalp to monitor heart rate.

Choice C rationale:

This is also correct. Internal monitoring provides the most accurate and continuous data about the baby’s heart rate.

Choice D rationale:

This is correct. The membranes must rupture before the electrode can be inserted.

A. "Why are you crying?". B. "A baby still wasn't formed in your uterus.”. C. "Will a pill help your pain?". D. "I'm sorry you lost your baby.”.

Correct Answer is D

Explanation

Choice A rationale:

Asking “Why are you crying?” may seem insensitive as it’s clear the client is upset due to the loss.

Choice B rationale:

Saying “A baby still wasn’t formed in your uterus.”. might be factually correct, but it can be hurtful as it dismisses the emotional attachment the client may have had.

Choice C rationale:

Offering a pill for pain might be practical, but it doesn’t address the emotional pain the client is likely experiencing.

Choice D rationale:

Saying “I’m sorry you lost your baby.”. acknowledges the client’s loss and offers sympathy, showing empathy and understanding.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?.

Correct Answer is A

Explanation

Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?.

Correct Answer is D

Explanation

Touch and massage can be helpful during labor. Which touch and massage methods are used in labor? Select all that apply.

While waiting for the placenta to deliver during the third stage of labor, the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?.

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?.

A woman in the 34th week of pregnancy says to the nurse, "I still feel like having intercourse with my husband.”. The woman's pregnancy has been uneventful. The nurse responds based on the understanding that:.

A nurse strongly encourages a pregnant client to avoid eating swordfish and tilefish because these fish contain which component?.

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station?.

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