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 C

Explanation

Choice A rationale:

Olive green is not the color nitrazine paper turns when it comes into contact with amniotic fluid.

Choice B rationale:

Pink is not the color nitrazine paper turns when it comes into contact with amniotic fluid.

Choice C rationale:

Blue is the color nitrazine paper turns when it comes into contact with amniotic fluid, indicating likely membrane rupture.

Choice D rationale:

Yellow is not the color nitrazine paper turns when it comes into contact with amniotic fluid.

A. Fundal height measurement. B. Fetal ultrasound. C. Urine for culture. D. Hemoglobin and hematocrit.

Correct Answer is A

Explanation

Choice A rationale:

Fundal height measurement is a common procedure during prenatal visits to monitor the baby’s growth.

Choice B rationale:

While ultrasounds are performed during pregnancy, they aren’t typically done at every prenatal visit.

Choice C rationale:

Urine cultures are important for detecting urinary tract infections, but they aren’t a routine part of every prenatal visit.

Choice D rationale:

Hemoglobin and hematocrit tests are done to check for anemia, but they aren’t typically performed at every visit.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client states "I think my water broke! I felt this gush of fluid between my legs.”. The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:.

Correct Answer is C

Explanation

When assessing a woman at follow-up prenatal visits, the nurse would anticipate which procedure to be performed?.

Correct Answer is A

Explanation

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?.

The nurse encourages a female client with human papillomavirus (HPV) to receive continued follow-up care because she is at risk for:.

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 teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. What will the mother likely experience at that time?.

A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which factors would the nurse include when discussing measures to promote coping for a positive labor experience? Select all that apply.

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?.

The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part?.

The pharmacy sends a bag of 150 mLs of D5W/0.456 normal saline with 25 units of Regular Insulin. The patient is ordered to receive an insulin drip at a rate of 9 units/hour. What rate will you set the IV pump to deliver? Numeric values only.