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. Sign of breast development. B. Sexual experience. C. Menstrual period. D. Full hormonal cycle.

Correct Answer is C

Explanation

Choice A rationale:

The first sign of breast development is not menarche. It is a part of puberty, but it is not the definition of menarche.

Choice B rationale:

A woman’s first sexual experience is not menarche. Menarche refers to a specific biological event.

Choice C rationale:

Menarche is defined as a woman’s first menstrual period. This is the correct definition.

Choice D rationale:

A full hormonal cycle is not menarche. While the hormonal cycle is related to menstruation, it is not the definition of menarche.

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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

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:.

Correct Answer is C

Explanation

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 providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment findings? Select all that apply.

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

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:.

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

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

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?.