The nurse is caring for a multiparous client who has been in labor for 12 hours. The client had a spontaneous vaginal delivery 2 years ago. This was an unplanned pregnancy with someone she only knew briefly. Since finding out she was pregnant, she has been alone. Her pain is now 8/10 and she is becoming fearful that something is wrong since she has been in labor so long.
Contractions assessment:
- Contractions every 3-4 minutes
- Palpating moderate in intensity
- Lasting 45-60 seconds Cervical exam: .3 cm
- 90% effaced . -2 station
- Fetus is in a cephalic presentation.
Which component of labor is keeping the client from advancing in labor?
Powers
Passage
Passenger
Psyche
The Correct Answer is D
A. Powers refer to uterine contractions and maternal pushing efforts, which seem appropriate based on the given information.
B. Passage refers to the birth canal, and there is no indication that the birth canal is obstructing the progress.
C. Passenger refers to the fetus, and the cephalic presentation is favorable for a vaginal delivery.
D. The client's psychological state, including fear and anxiety, can impact labor progress. The client's emotional and psychological well-being can influence the progression of labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An inverted nipple is not indicative of mastitis.
B. Presence of breast milk is expected postpartum and does not specifically indicate mastitis.
C. A bruised area is not a common sign of mastitis.
D. Mastitis often presents with localized pain, redness, swelling, and a hardening of the affected area of the breast. Asking about the presence of a hardening will help assess for mastitis.
Correct Answer is B
Explanation
A. Industry vs. inferiority is relevant to the age range of 6 to 12 years, focusing on the development of competence and mastery in skills. However, it may not be as directly related to the immediate care following an asthma exacerbation.
B. Initiative vs. guilt is the stage where a child starts to take more initiative and responsibility for their own actions. Planning home care involves encouraging the child to take initiative in
managing their asthma, promoting a sense of control over their health.
C. Identity vs. role confusion is more applicable to adolescence and focuses on the formation of a stable self-identity.
D. Autonomy vs. shame and doubt is relevant to the toddler age range, emphasizing the development of independence. While independence is important, the immediate concern in the given scenario aligns more with the initiative and responsibility associated with the school-age child.
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