Question

A nurse in a prenatal client is caring for a client who is at 38 weeks of gestation and has heavy, red vaginal bleeding, without contractions, that started spontaneously. She is in no distress and states that she can "feel the baby moving." The client should undergo an ultrasound to determine which of the following findings

Answer 1

Correct Answers:

Location of the placenta

Rationale :

🔹 Heavy, painless, bright red bleeding at 38 weeks strongly indicates placenta previa, where the placenta implants low and covers the cervical os.

🔹 An ultrasound is the safest, non-invasive diagnostic tool to confirm placental location, avoiding digital exams that could worsen hemorrhage.

🔹 Other tests like fetal lung maturity or Rh incompatibility are not immediately relevant; contractions are absent, so monitoring frequency/duration is not indicated.

🔹 Identifying placental placement is critical for determining the safest plan for delivery, usually cesarean birth if the placenta covers the cervix.

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Answer 2

Correct Answers:

Maturity of lungs

Rationale :

🔹 Amniocentesis performed in the third trimester (like during preterm labor) is used to assess fetal lung maturity by testing lecithin/sphingomyelin (L/S) ratio or presence of phosphatidylglycerol.

🔹 This helps determine if the fetus can survive outside the uterus without significant risk of respiratory distress syndrome.

🔹 While amniocentesis in the second trimester may identify genetic or anatomic abnormalities, the priority in preterm labor is lung maturity.

🔹 Gender and gestational age can be estimated through other means such as ultrasound, not amniocentesis at this stage.

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Answer 3

Correct Answers:

Umbilical cord compression

Rationale :

🌊 Variable decelerations are characterized by abrupt decreases in the fetal heart rate that vary in duration, intensity, and timing in relation to uterine contractions.

🌊 The primary cause is umbilical cord compression, which temporarily reduces blood flow and oxygen supply to the fetus.

🌊 Unlike early decelerations (caused by head compression) or late decelerations (caused by uteroplacental insufficiency), variable decelerations are sudden, irregular, and specifically linked to cord problems.

🌊 This finding alerts the nurse to closely monitor the fetus and implement interventions such as repositioning the client to relieve cord pressure.

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Answer 4

Correct Answers:

“Given too soon, epidural anesthesia can prolong labor."

Rationale :

⏱ Epidural anesthesia is generally delayed until a consistent labor pattern is established because it can slow the progression of labor if administered too early.

⏱ The medication decreases maternal ability to feel contractions and may reduce the strength of uterine contractions, interfering with effective labor.

⏱ Early administration may also reduce the mother’s urge to bear down, further prolonging labor and potentially increasing the need for interventions such as oxytocin augmentation.

⏱ Once labor is well-established, the epidural can provide effective pain relief while minimizing the risk of delayed cervical dilation or prolonged second stage.

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Answer 5

Correct Answers:

Cervical dilation

Rationale :

🌟True labor is confirmed by progressive cervical changes, specifically dilation and effacement, not just the presence of contractions or discomfort.

🌟Contractions may occur without actual cervical change, such as in false labor (Braxton Hicks).

🌟Amniotic fluid in the vaginal vault indicates rupture of membranes but does not confirm active labor.

🌟Pain above the navel is not a typical indicator of true labor.

🌟The hallmark sign that a client is truly in labor is cervical dilation and effacement documented by examination.

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Answer 6

Correct Answers:

The test predicts fetal well-being in the third trimester.

Rationale :

💎The biophysical profile (BPP) is a prenatal test that combines ultrasound with nonstress testing to assess fetal well-being in the third trimester.

💎It evaluates five parameters: fetal breathing movements, fetal body movements, fetal tone, amniotic fluid volume, and fetal heart rate reactivity.

💎A normal score indicates that the fetus is well-oxygenated and not in distress, while a low score suggests hypoxia and possible need for intervention.

💎This test is not used to determine estimated due date, nor does it require NPO status or initiation of labor interventions beforehand.

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Answer 7

Correct Answers:

Cephalohematoma

Rationale :

✨A cephalohematoma is a collection of blood between the skull bone and periosteum that appears as a swelling on the head which does not cross suture lines.

✨It typically develops a few hours after birth due to pressure or trauma during delivery, especially with the use of forceps or vacuum extraction.

✨Caput succedaneum, in contrast, is edema that crosses suture lines and resolves more quickly.

✨Molding refers to the shaping of the fetal head from pressure in the birth canal, and nevus flammeus is a flat, red-purple birthmark.

✨Recognizing cephalohematoma is important as it may increase the risk of jaundice from breakdown of red blood cells in the collected blood.

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Answer 8

Correct Answers:

Assess the perineum for signs of crowning

Rationale :

🔷When a client at 7 cm dilation suddenly feels the urge to push, the nurse must immediately assess for crowning, which indicates that delivery may be imminent.

🔷Pushing before complete dilation (10 cm) can cause cervical swelling and lacerations, so checking for crowning helps determine whether it is safe to push.

🔷If crowning is present, delivery preparation must begin promptly.

🔷Other comfort measures (positioning, panting, or bathroom use) are secondary to ensuring maternal and fetal safety when the urge to push arises.

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Answer 9

Correct Answers:

Fetal heart rate 100/min for a 10-min period

Rationale :

🌸A baseline fetal heart rate (FHR) should be between 110–160/min.

🌸A sustained rate of 100/min for 10 minutes indicates fetal bradycardia, which is a sign of possible fetal hypoxia or distress and must be reported immediately.

🌸Contractions lasting 85 seconds are still within acceptable limits (up to 90 sec).

🌸A resting period of 35 seconds and four contractions in 10 minutes are considered normal uterine activity patterns in active labor.

🌸Prompt recognition and reporting of bradycardia helps ensure timely interventions to improve fetal oxygenation.

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Answer 10

Correct Answers:

An external fetal monitor will be used to monitor the FHR

Rationale :

🌼A nonstress test (NST) is a noninvasive method of evaluating fetal well-being, typically in the third trimester.

🌼It involves applying an external fetal monitor to record the fetal heart rate (FHR) in response to fetal movement.

🌼A reactive NST shows accelerations of the FHR with fetal movement, which indicates adequate oxygenation and neurological function.

🌼It does not require IV access, ultrasound prior to the test, or nipple stimulation (that is part of a contraction stress test, not a routine NST).

🌼This test is safe, simple, and often used for clients with high-risk pregnancies or concerns about fetal health.

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QLexNursing

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

3 :
A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

4 :
A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse include?

5 :
A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirm that the client is in labor?

6 :
A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?

7 :
A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?

9 :
A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

10 :
A nurse is reinforcing teaching with a client who is scheduled for a nonstress test. Which of the following information should the nurse include?

QLexNursing

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

3 : A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

4 : A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse include?

5 : A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirm that the client is in labor?

6 : A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?

7 : A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?

9 : A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

10 : A nurse is reinforcing teaching with a client who is scheduled for a nonstress test. Which of the following information should the nurse include?

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

3 :
A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

4 :
A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse include?

5 :
A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirm that the client is in labor?

6 :
A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?

7 :
A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?

9 :
A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

10 :
A nurse is reinforcing teaching with a client who is scheduled for a nonstress test. Which of the following information should the nurse include?