The nurse is assessing a client who has been admitted in active labor.
The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom.
What should be the nurse’s first course of action?

Review the pattern of the fetal heart rate.

Check the client’s bladder.

Determine the dilation of the cervix.

Test the pH of the vaginal fluid.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: Reviewing the pattern of the fetal heart rate is important but not the immediate first step when a client in active labor needs to use the restroom. The nurse should first assess the progress of labor.

Choice B rationale: Checking the client's bladder is necessary, especially if the bladder is full, as it can affect labor progress. However, the priority is to assess the cervix first to ensure the client is not in an advanced stage of labor before addressing bladder concerns.

Choice C rationale: Determining the dilation of the cervix is crucial. The need to use the restroom may indicate increased pressure from the presenting part of the fetus, suggesting rapid labor progression. This assessment will help determine if it is safe for the client to ambulate to the restroom or if other immediate actions are needed.

Choice D rationale: Testing the pH of the vaginal fluid can be part of assessing for the presence of amniotic fluid, but it is not the first step when a client in active labor expresses the need to use the restroom. Cervical assessment takes priority in this situation.

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Correct Answer is C

Explanation

Choice A rationale

Unilateral lower leg pain is not a normal finding postpartum and could indicate a deep vein thrombosis, which requires immediate medical attention.

Choice B rationale

A soft, spongy fundus is not a normal finding postpartum. The uterus should be firm to prevent excessive bleeding.

Choice C rationale

A pulse rate of 56 beats/minute can be a normal finding postpartum. Pregnancy increases blood volume and cardiac output, and these changes can persist for some time after delivery.

Choice D rationale

Saturating two perineal pads per hour is not a normal finding postpartum and could indicate excessive bleeding.

A. Return of lochia rubra. B. Engorged, painful breasts. C. Difficulty falling asleep. D. Decreased appetite. E. Feelings of sadness.

Correct Answer is ["C","D","E"]

Explanation

Choice A rationale

Return of lochia rubra, or bright red bleeding, is not a sign of postpartum depression. It is a normal part of the postpartum period and can last for several weeks after childbirth.

Choice B rationale

Engorged, painful breasts can be a sign of breastfeeding complications, but they are not a sign of postpartum depression. They are a common experience for many women as their milk comes in after childbirth.

Choice C rationale

Difficulty falling asleep, even when the baby is sleeping, can be a sign of postpartum depression. Sleep disturbances are common among women with postpartum depression.

Choice D rationale

Decreased appetite can be a sign of postpartum depression. Changes in eating habits, such as eating too little or too much, are common symptoms of depression.

Choice E rationale

Feelings of sadness that last for more than two weeks after childbirth can be a sign of postpartum depression. While many women experience “baby blues” in the first few weeks after childbirth, prolonged feelings of sadness can indicate a more serious issue.

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The nurse is assessing a client who has been admitted in active labor. The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom. What should be the nurse’s first course of action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Correct Answer is C

Explanation

Which signs of postpartum depression require additional attention from the nurse? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.She is not currently convulsing.What intervention should the nurse plan to include in this client’s nursing care plan?

During a newborn assessment, which symptom, if present, would indicate respiratory distress?

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

A client who is scheduled for induction of labor receives a prescription for oxytocin 2 milliunits/min intravenously (IV). The IV bag contains oxytocin 20 units in lactated Ringer’s 1 liter. How many mL/hour should the nurse program the infusion pump to deliver? .

A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus.What action should the nurse take first?

A client, who is three days postpartum and formula feeding her newborn, reports experiencing painful, hard, and full breasts to the nurse.What recommendation should the nurse provide?

The nurse is assessing a client who has been admitted in active labor.
The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom.
What should be the nurse’s first course of action?