Question

The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for this client?

Answer 1

Correct Answers:

Intrauterine device

Rationale :

♦️ An intrauterine device (IUD) provides highly effective, long-acting reversible contraception, making it appropriate for a client who does not anticipate additional pregnancies but does not want permanent sterilization.

♦️ The client's statement that she “hates the thought of being sterile” indicates that a permanent contraceptive procedure would conflict with her preferences.

♦️ An IUD provides prolonged pregnancy prevention while preserving the possibility of future fertility after removal.

♦️ The client is 36 years old and smokes, making estrogen-containing contraceptive methods an important safety concern.

♦️ Combined hormonal contraceptives containing estrogen are generally contraindicated in clients 35 years or older who smoke because smoking increases cardiovascular and thrombotic risks.

♦️ Depending on the type selected, an IUD can provide contraception for several years without requiring daily adherence.

♦️ Having had multiple pregnancies does not prevent this client from using an IUD when no other contraindications are present.

♦️ Therefore, an IUD best meets her need for effective, long-term contraception that remains reversible and avoids estrogen exposure.

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Answer 2

Correct Answers:

Extent of cervical dilatation
Cervical effacement
Fetal presentation

Rationale :

✅ Extent of cervical dilatation

🖊️ A sterile vaginal examination allows the examiner to determine the degree of cervical dilatation during labor.

🖊️ Cervical dilatation describes the opening of the cervix and is measured in centimeters from 0 to 10 cm.

🖊️ A cervix that is 10 cm dilated is considered completely dilated.

🖊️ Progressive cervical dilatation is an important indicator of labor progression.

🖊️ The examiner estimates dilatation by determining the diameter of the cervical opening with gloved fingers.

🖊️ Serial examinations can help determine whether cervical change is occurring over time.

🖊️ Vaginal examinations should be performed only when clinically indicated to minimize the risk of ascending infection.

🖊️ Therefore, cervical dilatation is information obtained during a sterile vaginal examination.

✅ Cervical effacement

🖊️ A vaginal examination allows assessment of cervical effacement, which refers to thinning and shortening of the cervix.

🖊️ Effacement is traditionally documented as a percentage from 0% to 100%.

🖊️ A cervix that is 0% effaced is relatively long and thick.

🖊️ A cervix that is 100% effaced is completely thinned.

🖊️ Progressive effacement occurs as the cervix prepares for passage of the fetus during labor.

🖊️ Effacement and dilatation are important components used to assess labor progress.

🖊️ The examiner estimates cervical thickness and shortening through direct digital examination.

🖊️ Therefore, cervical effacement can be determined through a sterile vaginal examination.

✅ Fetal presentation

🖊️ A vaginal examination can help identify the presenting fetal part entering the maternal pelvis.

🖊️ Common fetal presentations include cephalic, breech, and shoulder presentations.

🖊️ In a cephalic presentation, the examiner can palpate fetal skull structures and sutures or fontanels.

🖊️ Identifying the presenting part helps evaluate how the fetus is positioned for vaginal birth.

🖊️ The examination can also provide information about fetal position and station when landmarks are palpable.

🖊️ Fetal station describes the relationship of the presenting part to the maternal ischial spines.

🖊️ Information about presentation is important for evaluating labor progress and identifying possible malpresentation.

🖊️ Therefore, fetal presentation can be assessed during a sterile vaginal examination.

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Answer 3

Correct Answers:

"You need to be in control of what happens, so you need to discuss contraceptive options before having sex again."

Rationale :

📘 The nurse should provide nonjudgmental, realistic, and developmentally appropriate contraceptive counseling to the adolescent.

📘 Discussing contraception supports the client's reproductive autonomy and helps prevent another unintended pregnancy.

📘 The statement encourages the adolescent to actively participate in decisions regarding her sexual and reproductive health.

📘 Adolescents may intend to abstain but later resume sexual activity, making advance discussion of contraceptive options important.

📘 Contraceptive counseling can include highly effective methods such as long-acting reversible contraception, along with other appropriate options.

📘 Counseling should also address condom use for STI prevention, because most other contraceptive methods do not protect against sexually transmitted infections.

📘 The nurse should avoid assumptions, criticism, or moral judgments regarding the teenager's previous or future sexual behavior.

📘 Therefore, discussing contraception before sexual activity resumes is the most therapeutic and preventive response.

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Answer 4

Correct Answers:

The client will be discharged home to await the onset of true labour

Rationale :

📗 The client is demonstrating findings consistent with false labor or the latent/prelabor period, rather than established active labor.

📗 Her contractions are mild, relatively short, and irregularly spaced, occurring every 5 to 9 minutes and lasting only 20 to 30 seconds.

📗 The cervix remains 1 cm dilated and uneffaced after 2 hours, demonstrating no progressive cervical change.

📗 True labor is characterized by regular contractions that progressively increase in frequency, duration, and intensity and produce cervical change.

📗 The Category I fetal heart rate indicates reassuring fetal status and does not suggest a need for immediate delivery.

📗 The client's membranes are intact, and there are no findings indicating an obstetric complication requiring hospitalization.

📗 A stable term client who is not in established labor can generally return home with instructions regarding when to return to the hospital.

📗 Therefore, discharge home to await the onset of true labor is the expected next step.

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Answer 5

Correct Answers:

Upon admission to the hospital at the start of labour
When the client feels perineal pressure
With either spontaneous or artificial rupture of membranes

Rationale :

✅ Upon admission to the hospital at the start of labour

🌸 A vaginal examination is commonly performed during the initial labor assessment when clinically appropriate.

🌸 The examination determines cervical dilatation and effacement, which help establish the client's labor status.

🌸 It can also identify the fetal presenting part, position, and station when these can be palpated.

🌸 Baseline cervical findings allow subsequent examinations to determine whether labor is progressing.

🌸 The examination also helps distinguish true labor from false labor by documenting cervical changes over time.

🌸 Vaginal examinations should be limited to those that are clinically necessary because repeated examinations can increase infection risk.

🌸 Special circumstances, such as unexplained vaginal bleeding or placenta previa, can make digital examination inappropriate until the cause is evaluated.

🌸 Therefore, an admission vaginal examination is appropriate when assessing a client presenting in labor.

✅ When the client feels perineal pressure

🌸 Increasing perineal or rectal pressure can indicate rapid fetal descent and progression toward the second stage of labor.

🌸 The sensation may occur as the presenting fetal part descends deeper into the maternal pelvis.

🌸 A vaginal examination can determine whether the cervix has reached complete dilatation.

🌸 The examination can also assess the station and descent of the presenting part.

🌸 This information is important before encouraging the client to begin active pushing.

🌸 Pushing before complete cervical dilatation can contribute to cervical edema or injury.

🌸 A sudden urge to bear down or increased pressure can indicate that birth is becoming imminent.

🌸 Therefore, new perineal pressure is an appropriate indication for a vaginal examination.

✅ With either spontaneous or artificial rupture of membranes

🌸 A vaginal examination may be indicated after rupture of membranes to evaluate the presenting part and assess for complications when clinically appropriate.

🌸 A major concern following membrane rupture is umbilical cord prolapse, particularly when the presenting part is not well engaged.

🌸 Cord prolapse can cause cord compression and acute fetal hypoxia.

🌸 The nurse should immediately assess the fetal heart rate following rupture of membranes because fetal bradycardia or variable decelerations can indicate cord compression.

🌸 Vaginal examination can help identify a prolapsed cord when fetal heart rate abnormalities or other clinical findings raise concern.

🌸 The examination can also provide information regarding cervical status and the relationship of the presenting part to the pelvis.

🌸 Examinations should still be minimized after membrane rupture because repeated vaginal examinations increase the risk of ascending infection.

🌸 Therefore, rupture of membranes is a circumstance in which vaginal assessment may be indicated.

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Answer 6

Correct Answers:

Encouraging clients to keep all prenatal appointments and if one needs to be missed to call and reschedule
Reporting symptoms of urinary frequency and burning to the health-care provider
Coming to the labour triage unit if back pain or cramping persist or become regular

Rationale :

✅ Encouraging clients to keep all prenatal appointments and if one needs to be missed to call and reschedule

🌼 Regular prenatal care allows healthcare providers to identify maternal or fetal conditions that can increase the risk of preterm labor and birth.

🌼 Prenatal appointments provide opportunities to assess maternal blood pressure, weight, fetal growth, and overall pregnancy progression.

🌼 Providers can identify risk factors such as infection, cervical changes, hypertension, or other pregnancy complications before they become severe.

🌼 Keeping scheduled appointments also provides opportunities for ongoing education about warning signs of preterm labor.

🌼 Clients who cannot attend an appointment should reschedule promptly rather than simply missing prenatal care.

🌼 Consistent prenatal monitoring supports early intervention when abnormalities are identified.

🌼 Early recognition and management of pregnancy complications can reduce the likelihood of adverse maternal and fetal outcomes.

🌼 Therefore, maintaining regular prenatal appointments is an important component of preterm birth prevention education.

✅ Reporting symptoms of urinary frequency and burning to the health-care provider

🌼 Urinary frequency accompanied by burning can indicate a urinary tract infection rather than normal pregnancy-related urinary frequency alone.

🌼 Maternal urinary tract infections are associated with an increased risk of preterm labor when they are not appropriately treated.

🌼 Pregnancy can increase susceptibility to urinary infections because of physiologic changes in the urinary tract.

🌼 Clients should promptly report symptoms such as dysuria, urgency, frequency, fever, or flank pain.

🌼 Early evaluation allows appropriate testing and treatment before the infection progresses.

🌼 Untreated infection can stimulate inflammatory responses that may contribute to uterine contractions and preterm birth.

🌼 Teaching clients to recognize infection symptoms promotes early intervention and reduces preventable complications.

🌼 Therefore, urinary frequency accompanied by burning should be reported promptly.

✅ Coming to the labour triage unit if back pain or cramping persist or become regular

🌼 Persistent low back pain and abdominal or menstrual-like cramping can be manifestations of preterm labor.

🌼 Preterm contractions may initially be mild and may not be recognized by the client as true uterine contractions.

🌼 Regular or progressively persistent cramping warrants prompt maternal and fetal evaluation.

🌼 Early assessment can determine whether contractions are producing cervical dilatation or effacement.

🌼 Other warning signs can include pelvic pressure, changes in vaginal discharge, vaginal spotting, or leaking fluid.

🌼 Prompt evaluation is particularly important when these symptoms occur before 37 completed weeks of gestation.

🌼 Early recognition provides an opportunity for appropriate interventions when indicated to improve maternal and neonatal outcomes.

🌼 Therefore, persistent or regular back pain and cramping should prompt evaluation in labor triage.

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Answer 7

Correct Answers:

Increased vaginal bleeding
Cord lengthens

Rationale :

✅ Increased vaginal bleeding

🏵️ During the third stage of labor, the placenta separates from the uterine wall after the birth of the newborn.

🏵️ A sudden gush or increase in vaginal bleeding is a classic sign that placental separation has occurred.

🏵️ Separation disrupts maternal blood vessels located at the placental implantation site.

🏵️ Blood can collect behind the separating placenta before becoming visible vaginally.

🏵️ As the placenta separates more completely, this accumulated blood may suddenly be expelled through the vagina.

🏵️ Other signs of placental separation should be assessed together rather than relying on bleeding alone.

🏵️ The uterus also typically becomes firm, globular, and rises in the abdomen as separation occurs.

🏵️ Therefore, increased vaginal bleeding is an expected sign of placental separation.

✅ Cord lengthens

🏵️ Lengthening of the umbilical cord at the vaginal opening is another classic sign of placental separation.

🏵️ Once separated, the placenta descends from the uterine wall into the lower uterine segment and vagina.

🏵️ As the placenta moves downward, more of the attached umbilical cord becomes visible externally.

🏵️ The nurse therefore observes an apparent increase in the length of the cord outside the vagina.

🏵️ Cord lengthening commonly occurs along with a gush of blood and changes in uterine shape.

🏵️ These findings indicate progression through the third stage of labor.

🏵️ The cord should not be pulled forcefully because inappropriate traction can contribute to serious complications.

🏵️ Therefore, cord lengthening is a characteristic sign that the placenta has separated.

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Answer 8

Correct Answers:

Prepare to assist the mother with the birth and call for assistance.

Rationale :

🌹 Crowning occurs when the fetal head remains visible at the vaginal opening and indicates that birth is imminent.

🌹 The nurse should remain with the client and immediately prepare to assist with the birth rather than leaving her unattended.

🌹 The nurse should simultaneously call for additional assistance because another healthcare professional may be needed to support the mother and newborn.

🌹 Completing routine procedures such as the perineal preparation becomes secondary once imminent birth is recognized.

🌹 The nurse should support the fetal head as it emerges while allowing birth to occur in a controlled manner.

🌹 Appropriate support helps minimize rapid expulsion of the fetal head and reduces unnecessary maternal tissue trauma.

🌹 The nurse should be prepared to provide immediate newborn assessment, warming, airway support if needed, and maternal care following birth.

🌹 Therefore, preparing to assist with the birth while calling for assistance is the safest response when crowning occurs.

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Answer 9

Correct Answers:

Chronic diabetes, post term, history of rapid labor

Rationale :

🖊️ Chronic diabetes can be an indication for induction because prolonged pregnancy can increase maternal and fetal complications, including macrosomia and placental dysfunction.

🖊️ The timing of delivery in a client with diabetes depends on glycemic control, fetal status, and maternal complications.

🖊️ A post-term pregnancy is an established indication for induction because risks increase as pregnancy continues beyond the recommended gestational period.

🖊️ Post-term pregnancy increases the risk of placental insufficiency, oligohydramnios, macrosomia, and meconium aspiration.

🖊️ A history of rapid or precipitous labor can be considered for planned induction when appropriate because of the risk of an unplanned birth before reaching the healthcare facility.

🖊️ Induction should only occur when the benefits of delivery outweigh the risks of continuing the pregnancy.

🖊️ Before induction, the healthcare team evaluates fetal presentation, cervical readiness, fetal status, and contraindications to vaginal birth.

🖊️ Therefore, chronic diabetes, post-term pregnancy, and a history of rapid labor represent the appropriate group of indications among these choices.

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Answer 10

Correct Answers:

100

Rationale :

Formula:

mL/hr = Dose prescribed ÷ Dose available × Volume available

➤ Dose prescribed = 2 g/hr

➤ Dose available = 20 g

➤ Volume available = 1000 mL

2 g ÷ 20 g × 1000 mL = 100 mL/hr

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QLexNursing

1 :
The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for this client?

2 :
The perinatal nurse knows that a sterile vaginal examination provides what information? Select all that apply.

3 :
A postpartum teenage mother tells the nurse that she "will not get pregnant again." Which is the nurse's best response to this statement?

5 :
Vaginal examination should be performed in which of these circumstances? Select all that apply.

6 :
The perinatal nurse provides a hospital tour for couples and families preparing for labour and birth. Teaching is an important component of the tour. What information would be provided about preterm labour and birth prevention? Select the three (3) that apply.

7 :
Which two (2) are signs of placental separation in the 3rd Stage of Labour? Select the two (2) that apply.

8 :
After assisting the client to a comfortable position for birth, the nurse begins cleansing the woman's perineal area. With the next contraction, the baby's head crowns and birth is imminent. What should the nurse do?

9 :
The nurse understands which of the following are appropriate indications for induction of labour?

10 :
Your patient is being started on Magnesium Sulfate. The order states administer Magnesium Sulfate at continuous rate of 2g/hr. Magnesium Sulfate is supplied as 20g/1000ml NS. What would you set your pump at for the continuous infusion? ml/hr

QLexNursing

1 : The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for this client?

2 : The perinatal nurse knows that a sterile vaginal examination provides what information? Select all that apply.

3 : A postpartum teenage mother tells the nurse that she "will not get pregnant again." Which is the nurse's best response to this statement?

5 : Vaginal examination should be performed in which of these circumstances? Select all that apply.

6 : The perinatal nurse provides a hospital tour for couples and families preparing for labour and birth. Teaching is an important component of the tour. What information would be provided about preterm labour and birth prevention? Select the three (3) that apply.

7 : Which two (2) are signs of placental separation in the 3rd Stage of Labour? Select the two (2) that apply.

8 : After assisting the client to a comfortable position for birth, the nurse begins cleansing the woman's perineal area. With the next contraction, the baby's head crowns and birth is imminent. What should the nurse do?

9 : The nurse understands which of the following are appropriate indications for induction of labour?

10 : Your patient is being started on Magnesium Sulfate. The order states administer Magnesium Sulfate at continuous rate of 2g/hr. Magnesium Sulfate is supplied as 20g/1000ml NS. What would you set your pump at for the continuous infusion? ml/hr

1 :
The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for this client?

2 :
The perinatal nurse knows that a sterile vaginal examination provides what information? Select all that apply.

3 :
A postpartum teenage mother tells the nurse that she "will not get pregnant again." Which is the nurse's best response to this statement?

5 :
Vaginal examination should be performed in which of these circumstances? Select all that apply.

6 :
The perinatal nurse provides a hospital tour for couples and families preparing for labour and birth. Teaching is an important component of the tour. What information would be provided about preterm labour and birth prevention? Select the three (3) that apply.

7 :
Which two (2) are signs of placental separation in the 3rd Stage of Labour? Select the two (2) that apply.

8 :
After assisting the client to a comfortable position for birth, the nurse begins cleansing the woman's perineal area. With the next contraction, the baby's head crowns and birth is imminent. What should the nurse do?

9 :
The nurse understands which of the following are appropriate indications for induction of labour?

10 :
Your patient is being started on Magnesium Sulfate. The order states administer Magnesium Sulfate at continuous rate of 2g/hr. Magnesium Sulfate is supplied as 20g/1000ml NS. What would you set your pump at for the continuous infusion? ml/hr