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 B

Explanation

Choice A rationale:

Bradypnea and hypertension are not typically signs of impending shock.

Choice B rationale:

Tachycardia and a falling blood pressure are classic signs of shock as the body tries to compensate for the decreased blood flow.

Choice C rationale:

Tachypnea and a widening pulse pressure can be signs of shock, but they are not as indicative as tachycardia and a falling blood pressure.

Choice D rationale:

Bradycardia and auscultation of fluid in the base of the lungs are not typically signs of impending shock.

A. Olive green. B. Pink. C. Blue. D. Yellow.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?.

Correct Answer is B

Explanation

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

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

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?.

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:.

Which action is a priority when caring for a woman during the fourth stage of labor?.

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?.

When teaching a group of postmenopausal women about hot flashes and night sweats, the nurse would address which primary cause?.

Assessment of a female client reveals a thick, white vaginal discharge. The client also reports intense itching and dyspareunia. Based on these findings, the nurse would suspect that the client has:.

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