Question

A nurse is caring for a client who wants to know if it is possible to have a trial of labor for a vaginal birth after a cesarean birth (TOLAC.. Which of the following statements by the nurse is appropriate?

Answer 1

Correct Answers:

"The primary consideration for a safe attempt at a vaginal birth after cesarean (VBAC. is what type of incision you had."

Rationale :

🔷 The type of uterine incision is crucial for determining VBAC safety. Low transverse incisions are associated with a lower risk of uterine rupture and may allow for a trial of labor.

🔷 Other incision types, such as classical (vertical), carry a higher risk and usually contraindicate TOLAC.

🔷 Clear communication about incision type helps guide counseling and safe delivery planning.

🔷 Patient-specific evaluation, not a blanket recommendation, is evidence-based care.

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Answer 2

Correct Answers:

Maturity of lungs

Rationale :

🟢 The L/S ratio (lecithin/sphingomyelin) in amniotic fluid is tested by amniocentesis to assess fetal lung maturity, especially in cases of preterm labor risk.

🟢 A ratio ≥2:1 suggests adequate surfactant and mature fetal lungs.

🟢 This guides timing and management of preterm delivery.

🟢 Other options (gender, anatomic abnormalities, gestational age) are not assessed with the L/S ratio.

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Answer 3

Correct Answers:

"The primary consideration for a safe attempt at a vaginal birth after cesarean (VBAC. is what type of incision you had."

Rationale :

🔷 Uterine incision type (especially low transverse) determines eligibility for VBAC due to lower rupture risk. 🔷 Knowing this guides both nurse and client in planning a safe delivery. 🔷 Not all prior cesareans preclude TOLAC; specifics must be reviewed. 🔷 Encouraging informed discussion supports patient autonomy.

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Answer 4

Correct Answers:

Hepatitis B immune globulin and the hepatitis B vaccine within 12 hr of birth

Rationale :

🟡 Infants born to hepatitis B-positive mothers must receive both the vaccine and immune globulin within 12 hours to prevent perinatal transmission.

🟡 This dual approach is more effective than either alone and is the recommended standard.

🟡 Delaying or staggering doses increases infection risk.

🟡 Prompt administration is crucial for lifelong protection.

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Answer 5

Correct Answers:

Call the lactation consultant to visit the patient
Encourage and support the mother's desire/intention and include the partner in the conversation
Check for audible swallowing and a comfortable (non-painful) suck
Assist with proper positioning and latch techniques

Rationale :

🔴 Lactation consultant expertise supports both technical and emotional aspects of breastfeeding.

🔴 Emotional support and partner involvement encourage confidence and bonding.

🔴 Audible swallowing and non-painful suck indicate effective feeding and milk transfer.

🔴 Hands-on help with positioning and latch can resolve most early breastfeeding challenges.

🔴 Formula and forceful techniques are discouraged unless medically indicated.

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Answer 6

Correct Answers:

Position the client on her side.

Rationale :

🔵 Late decelerations signal uteroplacental insufficiency. First action is to turn the client on her side to improve blood flow and oxygenation to the fetus.

🔵 This position relieves vena cava compression and maximizes perfusion.

🔵 Oxygen and fluids can follow, but positioning is always immediate.

🔵 Side-lying is prioritized before escalating interventions.

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Answer 7

Correct Answers:

Dry and stimulate the newborn: position and open the airway, clear secretions if necessary

Rationale :

🟣 The first priority in neonatal resuscitation is to establish and maintain a clear airway, dry, and stimulate the newborn for effective breathing.

🟣 This supports transition from intrauterine to extrauterine life.

🟣 Medications, identification, and documentation are done after ABCs are secured.

🟣 Prompt, skilled airway management saves lives.

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Answer 8

Correct Answers:

The number of wet diapers per day

Rationale :

🟢 Wet diaper count is the most reliable and objective sign of neonatal hydration in the first days.

🟢 Adequate output (typically 6-8 wet diapers daily by day 5) confirms sufficient intake.

🟢 Skin turgor, crying, or clothing fit are less specific for early hydration assessment.

🟢 Tracking diaper output reassures both nurse and family.

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Answer 9

Correct Answers:

Check for blood under the client's buttock.

Rationale :

🟡 With a firm, midline fundus and small lochia, concealed bleeding may occur and pool under the client.

🟡 Always check under the buttocks to rule out hidden hemorrhage, especially early postpartum.

🟡 A firm uterus generally rules out atony as a bleeding cause.

🟡 Vigilance prevents missed hemorrhage.

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Answer 10

Correct Answers:

The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines.

Rationale :

🔷 Vaginal exam notation is: dilation (cm), effacement (%), and station (relation to ischial spines).

🔷 "-1" station means the presenting part is 1 cm above the spines.

🔷 Accurate interpretation guides labor progress and timing of interventions.

🔷 Understanding labor terminology is vital for safe care.

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QLexNursing

1 :
A nurse is caring for a client who wants to know if it is possible to have a trial of labor for a vaginal birth after a cesarean birth (TOLAC.. Which of the following statements by the nurse is appropriate?

2 :
A nurse is assisting with the care of a client who is experiencing preterm labor and is scheduled to undergo amniocentesis for L/S ratio. The client needs an amniocentesis to determine which of the following findings?

3 :
A nurse is caring for a client who wants to know if it is possible to have a trial of labor for a vaginal birth after a cesarean birth (TOLAC.. Which of the following statements by the nurse is appropriate?

4 :
A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive?

5 :
Your patient who wants to exclusively breastfeed is afraid her baby isn't latching properly. To assist the mother you would (Select all that apply)

6 :
A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take FIRST?

7 :
A nurse is caring for a newborn immediately following delivery. Which of the following actions should be the nurse's priority in the resuscitation of this neonate?

8 :
A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?

9 :
A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at one fingerbreadth above the umbilicus. Which of the following actions should the nurse take?

10 :
A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

QLexNursing

1 : A nurse is caring for a client who wants to know if it is possible to have a trial of labor for a vaginal birth after a cesarean birth (TOLAC.. Which of the following statements by the nurse is appropriate?

2 : A nurse is assisting with the care of a client who is experiencing preterm labor and is scheduled to undergo amniocentesis for L/S ratio. The client needs an amniocentesis to determine which of the following findings?

3 : A nurse is caring for a client who wants to know if it is possible to have a trial of labor for a vaginal birth after a cesarean birth (TOLAC.. Which of the following statements by the nurse is appropriate?

4 : A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive?

5 : Your patient who wants to exclusively breastfeed is afraid her baby isn't latching properly. To assist the mother you would (Select all that apply)

6 : A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take FIRST?

7 : A nurse is caring for a newborn immediately following delivery. Which of the following actions should be the nurse's priority in the resuscitation of this neonate?

8 : A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?

9 : A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at one fingerbreadth above the umbilicus. Which of the following actions should the nurse take?

10 : A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

1 :
A nurse is caring for a client who wants to know if it is possible to have a trial of labor for a vaginal birth after a cesarean birth (TOLAC.. Which of the following statements by the nurse is appropriate?

2 :
A nurse is assisting with the care of a client who is experiencing preterm labor and is scheduled to undergo amniocentesis for L/S ratio. The client needs an amniocentesis to determine which of the following findings?

3 :
A nurse is caring for a client who wants to know if it is possible to have a trial of labor for a vaginal birth after a cesarean birth (TOLAC.. Which of the following statements by the nurse is appropriate?

4 :
A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive?

5 :
Your patient who wants to exclusively breastfeed is afraid her baby isn't latching properly. To assist the mother you would (Select all that apply)

6 :
A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take FIRST?

7 :
A nurse is caring for a newborn immediately following delivery. Which of the following actions should be the nurse's priority in the resuscitation of this neonate?

8 :
A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?

9 :
A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at one fingerbreadth above the umbilicus. Which of the following actions should the nurse take?

10 :
A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?