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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A rationale:
Cervical effacement of 30% is more indicative of the early phase of labor, not the active phase. In the active phase, effacement is usually 80-100%.
Choice B rationale:
A strong desire to push is usually associated with the transition phase of labor, not the active phase.
Choice C rationale:
Contractions every 90 seconds could be indicative of the active phase, but this can vary between individuals.
Choice D rationale:
Cervical dilation of 6 cm is indeed indicative of the active phase of labor, which is typically characterized by cervical dilation of 4-7 cm.
Choice E rationale:
Contractions every 2 to 3 minutes are common in the active phase of labor.
Correct Answer is B
Explanation
Choice A rationale:
Dysuria is not typically associated with lightening.
Choice B rationale:
Urinary frequency can increase when lightening occurs because the baby drops into the pelvis, putting more pressure on the bladder.
Choice C rationale:
Constipation is not typically associated with lightening.
Choice D rationale:
Dyspnea can actually improve when lightening occurs because there is less pressure on the diaphragm.
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