Question

A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include?

Answer 1

Correct Answers:

Fetal heart tones detected by ultrasound.

Rationale :

🩺 Positive signs of pregnancy are those that are directly attributable to the presence of a fetus.

📻 Fetal heart tones heard via ultrasound or Doppler are irrefutable evidence of pregnancy.

🛌 Fatigue and breast tenderness are presumptive signs, which may be due to other causes like hormonal changes or illness.

🧪 A positive pregnancy test is a probable sign, as false positives can occur (e.g., certain tumors or medications).

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Answer 2

Correct Answers:

"This could result in profound bleeding."

Rationale :

🚫 In placenta previa, the placenta partially or completely covers the cervical os.

💉 Performing a digital or internal exam can disrupt the placenta and cause severe hemorrhage.

🛑 This is a medical emergency, and internal exams are avoided until placenta location is confirmed via ultrasound.

🦠 While infection and rupture are concerns, the main priority is bleeding control.

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Answer 3

Correct Answers:

"My baby's temperature will be checked rectally every hour."

Rationale :

🌡️ Rectal temperatures are not routinely used in newborns due to the risk of mucosal injury or perforation.

⏰ Temperature monitoring is typically done axillary every 4 hours unless otherwise indicated.

🧣 Covering the baby's head and keeping them away from drafts are appropriate thermal regulation practices.

🫂 Placing the baby skin-to-skin or on the mother’s chest promotes thermoregulation and bonding.

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Answer 4

Correct Answers:

Cervix dilation of 5 cm with 50% effacement.

Rationale :

🌀 Labor has three stages, with the first stage ending at full cervical dilation (10 cm) and 100% effacement.

🔄 Dilation from 0 to 10 cm occurs during the first stage; transition to second stage begins once fully dilated.

💧 Ruptured membranes and regular contractions can occur early and are not indicators of stage transition.

👶 Full dilation means the mother is ready to push during the second stage.

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Answer 5

Correct Answers:

Clear the respiratory tract.

Rationale :

🌬️ Airway patency is the first priority in neonatal care — remember ABC: Airway, Breathing, Circulation.

👃 Suctioning the mouth and nose prevents aspiration of secretions that can obstruct breathing.

🩺 Stimulation to cry, drying, and head covering are important but follow airway clearance.

🔗 The umbilical cord is typically clamped and cut once the newborn is stable.

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Answer 6

Correct Answers:

Sitz baths increase the blood supply to the perineal area.

Rationale :

💧 Warm sitz baths promote vasodilation, not vasoconstriction, which enhances blood flow and healing.

🩸 Increased circulation to the area helps reduce swelling, discomfort, and promotes tissue repair.

🚿 They also provide cleansing and comfort for perineal trauma or episiotomy.

⚠️ Sitz baths do not increase infection risk when done correctly.

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Answer 7

Correct Answers:

When the cervix is fully dilated.

Rationale :

🎯 Pushing begins during the second stage of labor, which starts at 10 cm dilation.

🧍 Premature pushing (before full dilation) can cause cervical edema and delayed progress.

👩‍⚕️ While the provider’s presence is important, physiological readiness is the true indicator.

👶 The fetal head becoming visible (crowning) comes after pushing has begun, not before.

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Answer 8

Correct Answers:

She did her perineal care independently.

Rationale :

👩‍👧 The taking-hold phase is characterized by increased independence and maternal involvement in self-care and infant care.

🧠 Mothers begin focusing on learning and adapting to their new role and responsibilities.

🎙️ Talking about the birth experience occurs in the taking-in phase, which is more passive.

🧸 Rocking the baby or nurturing behaviors emerge later as bonding deepens.

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Answer 9

Correct Answers:

Between 24 and 28 weeks' gestation.

Rationale :

🧪 Screening for gestational diabetes mellitus (GDM) is routinely done during weeks 24–28 when placental hormones can impair insulin sensitivity.

🩸 This includes a glucose challenge test (GCT) or oral glucose tolerance test (OGTT).

📅 Screening earlier (8–12 weeks) is reserved for high-risk clients (e.g., obesity, prior GDM).

📈 Testing too late may miss opportunities for early intervention and risk reduction.

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Answer 10

Correct Answers:

The presenting part is 1 cm above the ischial spines.

Rationale :

📍 Station refers to the fetal descent in relation to the ischial spines. A -1 station means the presenting part is 1 cm above these spines.

📍 The ischial spines are the narrowest part of the pelvis and the reference point for 0 station.

📍 +1 to +5 indicate how far the baby has descended past the ischial spines; engagement begins at 0.

📍 Confusing station with dilation or effacement is common but incorrect.

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QLexNursing

1 :
A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include?

2 :
A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

3 :
A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching?

4 :
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?

5 :
A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

6 :
Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?

7 :
At what time is the laboring client encouraged to push?

8 :
A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

9 :
Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and birth.
The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?

10 :
A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

QLexNursing

1 : A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include?

2 : A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

3 : A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching?

4 : A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?

5 : A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

6 : Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?

7 : At what time is the laboring client encouraged to push?

8 : A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

9 : Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and birth.The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?

10 : A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

1 :
A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include?

2 :
A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

3 :
A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching?

4 :
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?

5 :
A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

6 :
Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?

7 :
At what time is the laboring client encouraged to push?

8 :
A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

9 :
Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and birth.
The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?

10 :
A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?