Question

A nurse in a prenatal clinic is caring for a client who is 39 weeks gestation. The nurse educates the client on signs of impending labor. What sign should the nurse include in the education?

Answer 1

Correct Answers:

Lightening

Rationale :

💎 The fetus descends into the pelvis (lightening), relieving pressure on the diaphragm but increasing bladder pressure.

💎 This occurs 1–2 weeks before labor in primigravidas and closer to labor onset in multigravidas.

💎 The woman may experience urinary frequency and easier breathing after lightening.

💎 It indicates fetal engagement and cervical preparation for dilation.

💎 Nurses should educate clients to note pelvic pressure and increased vaginal discharge as accompanying signs.

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Answer 2

Correct Answers:

"A suction cup will be applied to the newborn's head during delivery."

Rationale :

🔷 This statement is incorrect because a suction cup is used in vacuum extraction, not forceps delivery.

🔷 Forceps are metal instruments that grasp the fetal head to assist rotation or descent during vaginal delivery.

🔷 Proper use requires a fully dilated cervix and ruptured membranes to prevent injury.

🔷 Forceps use can cause facial bruising or lacerations, which usually resolve spontaneously.

🔷 Nurses monitor for facial palsy, scalp edema, or bruising in the newborn after delivery.

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Answer 3

Correct Answers:

The fetus is in a breech position

Rationale :

💠 A hard, round fetal part in the fundus indicates the fetal head, which confirms breech presentation.

💠 If the buttocks were in the fundus, the nurse would palpate a soft, irregular mass instead.

💠 Leopold’s maneuvers help determine fetal lie, presentation, and position to plan delivery.

💠 Breech position means the buttocks or feet are presenting first, increasing cesarean delivery risk.

💠 Continuous fetal monitoring is essential due to higher risk for cord prolapse or head entrapment.

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Answer 4

Correct Answers:

A client who is 34 weeks pregnant with twins.

Rationale :

🔶 Multiple gestation causes uterine overdistention, leading to early contractions and cervical shortening.

🔶 Twin pregnancies have higher rates of preterm labor and premature rupture of membranes (PROM).

🔶 Other risks include polyhydramnios, infection, and placental insufficiency.

🔶 Nurses educate clients on preterm warning signs: contractions, back pain, and pelvic pressure.

🔶 Close prenatal monitoring, rest, and hydration are essential to delay labor onset.

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Answer 5

Correct Answers:

Cervical dilation
Blood pressure
Fetal heart rate variability
Contraction frequency

Rationale :

🟢 Cervical dilation helps determine the stage and progress of labor.

🟢 Blood pressure must be monitored for maternal safety, as preeclampsia can mimic labor symptoms.

🟢 Fetal heart rate variability indicates fetal oxygenation and neurological function.

🟢 Contraction frequency provides insight into labor strength and regularity.

🟢 Estimated fetal weight and fetal response to oxytocin are not part of initial triage; they’re assessed later in labor.

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Answer 6

Correct Answers:

Accelerations present

Rationale :

🔶 Accelerations are temporary increases in fetal heart rate, indicating adequate oxygenation and fetal well-being.

🔶 They are expected findings and reassure the nurse that fetal acid-base balance is stable.

🔶 Occur due to fetal movement, uterine contractions, or external stimulation.

🔶 Presence of accelerations helps rule out hypoxia or distress.

🔶 Continuous monitoring ensures early recognition of deviations from normal patterns.

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Answer 7

Correct Answers:

Moderate amount of rubra lochia
Fundus is firm and midline
Small clots expressed with fundal check

Rationale :

🔷 Moderate rubra lochia (dark red discharge) is normal in the early postpartum period.

🔷 Firm, midline fundus indicates effective uterine contraction and minimal risk of hemorrhage.

🔷 Small clots can appear when fundal pressure releases pooled blood; large clots require evaluation.

🔷 Uterine atony and hypotension suggest abnormal bleeding or shock.

🔷 Teaching should include frequent pad changes and uterine tone checks.

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Answer 8

Correct Answers:

Notify the healthcare provider
Change the client's position
Perform a sterile vaginal exam
Prepare for cesarean delivery
Administer IV fluids

Rationale :

💎 Variable decelerations are caused by umbilical cord compression, reducing fetal oxygenation.

💎 Repositioning (side-lying or knee-chest) relieves cord pressure.

💎 IV fluid bolus improves placental perfusion and maternal blood volume.

💎 Sterile exam rules out cord prolapse or rapid cervical change.

💎 Notify provider and prepare for C-section if decelerations persist despite interventions.

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Answer 9

Correct Answers:

An IUD is contraindicated in clients with active pelvic infections.
An IUD can increase the likelihood of an ectopic pregnancy.
An IUD is considered a highly effective form of birth control.

Rationale :

💎 Contraindicated with active pelvic infection: An IUD should not be inserted in clients with pelvic inflammatory disease (PID) or cervicitis to prevent infection from ascending into the uterus.

💎 Risk of ectopic pregnancy: While the IUD prevents intrauterine conception, if pregnancy occurs, it’s more likely to be ectopic because the fallopian tubes remain open.

💎 Highly effective birth control: IUDs are over 99% effective, making them one of the most reliable long-term reversible contraceptives (LARC) available.

💎 The device works by creating a localized inflammatory response that impairs sperm motility and fertilization.

💎 Nurses educate clients that fertility returns immediately upon IUD removal, unlike sterilization which is permanent.

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Answer 10

Correct Answers:

Explain that uterine cramping is a normal response to breastfeeding.

Rationale :

🔷 Breastfeeding stimulates the release of oxytocin from the posterior pituitary gland, causing uterine contractions.

🔷 These contractions help the uterus return to pre-pregnancy size (involution) and reduce postpartum bleeding.

🔷 Mild cramping is a normal physiological response, especially noticeable in multiparous women.

🔷 The nurse should reassure the client that this discomfort is temporary and beneficial for recovery.

🔷 If pain is severe, mild analgesics compatible with breastfeeding (like ibuprofen) can be offered.

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QLexNursing

1 :
A nurse in a prenatal clinic is caring for a client who is 39 weeks gestation. The nurse educates the client on signs of impending labor. What sign should the nurse include in the education?

2 :
A nurse is educating a new graduate nurse about forceps-assisted deliveries. What statement by the new graduate indicates a need for further education?

3 :
The nurse is performing Leopold's maneuver on a 39-week pregnant client. When palpating the fundus, the nurse feels a hard, round fetal part. What should the nurse conclude?

4 :
The nurse is working in an obstetric clinic. Which client is at greatest risk for preterm labor?

5 :
The nurse is triaging a 38-week pregnant client who arrived at the labor and delivery unit with contractions. What should the nurse include in the triage assessment of the client? Select all that apply.

6 :
The nurse is caring for a laboring client. What should the nurse include in the documentation of this fetal monitoring?

7 :
A client delivered a healthy B-pound 3-ounce infant one hour ago. Which assessment finding(s) should the nurse expect? Select all that apply.

8 :
The nurse is caring for a client in labor and notes recurrent variable decelerations on the fetal monitor. What action(s) should the nurse take at this time? Select all that apply.

9 :
The nurse is planning education for a client who desires to have an intrauterine device (IUD) inserted. Which information should the nurse plan to include? Select all that apply

10 :
The nurse is caring for a client who reports increased uterine cramping when breastfeeding. What is an appropriate nursing action?

QLexNursing

1 : A nurse in a prenatal clinic is caring for a client who is 39 weeks gestation. The nurse educates the client on signs of impending labor. What sign should the nurse include in the education?

2 : A nurse is educating a new graduate nurse about forceps-assisted deliveries. What statement by the new graduate indicates a need for further education?

3 : The nurse is performing Leopold's maneuver on a 39-week pregnant client. When palpating the fundus, the nurse feels a hard, round fetal part. What should the nurse conclude?

4 : The nurse is working in an obstetric clinic. Which client is at greatest risk for preterm labor?

5 : The nurse is triaging a 38-week pregnant client who arrived at the labor and delivery unit with contractions. What should the nurse include in the triage assessment of the client? Select all that apply.

6 : The nurse is caring for a laboring client. What should the nurse include in the documentation of this fetal monitoring?

7 : A client delivered a healthy B-pound 3-ounce infant one hour ago. Which assessment finding(s) should the nurse expect? Select all that apply.

8 : The nurse is caring for a client in labor and notes recurrent variable decelerations on the fetal monitor. What action(s) should the nurse take at this time? Select all that apply.

9 : The nurse is planning education for a client who desires to have an intrauterine device (IUD) inserted. Which information should the nurse plan to include? Select all that apply

10 : The nurse is caring for a client who reports increased uterine cramping when breastfeeding. What is an appropriate nursing action?

1 :
A nurse in a prenatal clinic is caring for a client who is 39 weeks gestation. The nurse educates the client on signs of impending labor. What sign should the nurse include in the education?

2 :
A nurse is educating a new graduate nurse about forceps-assisted deliveries. What statement by the new graduate indicates a need for further education?

3 :
The nurse is performing Leopold's maneuver on a 39-week pregnant client. When palpating the fundus, the nurse feels a hard, round fetal part. What should the nurse conclude?

4 :
The nurse is working in an obstetric clinic. Which client is at greatest risk for preterm labor?

5 :
The nurse is triaging a 38-week pregnant client who arrived at the labor and delivery unit with contractions. What should the nurse include in the triage assessment of the client? Select all that apply.

6 :
The nurse is caring for a laboring client. What should the nurse include in the documentation of this fetal monitoring?

7 :
A client delivered a healthy B-pound 3-ounce infant one hour ago. Which assessment finding(s) should the nurse expect? Select all that apply.

8 :
The nurse is caring for a client in labor and notes recurrent variable decelerations on the fetal monitor. What action(s) should the nurse take at this time? Select all that apply.

9 :
The nurse is planning education for a client who desires to have an intrauterine device (IUD) inserted. Which information should the nurse plan to include? Select all that apply

10 :
The nurse is caring for a client who reports increased uterine cramping when breastfeeding. What is an appropriate nursing action?