Question

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

Answer 1

Correct Answers:

Changes in the cervix

Rationale :

✍️ True labor is primarily indicated by progressive cervical changes, including effacement (thinning) and dilation.

✍️ While contraction patterns and rupture of membranes may occur, they do not definitively confirm true labor.

✍️ The station of the presenting part refers to fetal descent, which may not be evident at the start of true labor.

✍️ Assessing cervical changes provides the best confirmation of active labor progression.

✍️ Recognizing this helps nurses accurately determine labor status and plan care.

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Answer 2

Correct Answers:

Place the client in a lateral position

Rationale :

☑️ Epidural anesthesia can cause maternal hypotension due to vasodilation.

☑️ Placing the client in a lateral position helps relieve pressure on the vena cava, improving venous return and increasing blood pressure.

☑️ This position also promotes better fetal oxygenation and stabilizes fetal heart rate.

☑️ Elevating legs or monitoring vital signs is important but secondary to correcting hypotension.

☑️ Prompt positioning is the priority nursing intervention.

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Answer 3

Correct Answers:

Variable decelerations are due to umbilical cord compression

Rationale :

🟢 Variable decelerations are characterized by abrupt decreases in fetal heart rate unrelated to contractions’ timing.

🟢 They are caused by umbilical cord compression, which reduces blood flow and oxygen to the fetus temporarily.

🟢 This differs from early decelerations (fetal head compression) and late decelerations (uteroplacental insufficiency).

🟢 Variable decelerations may require nursing interventions such as repositioning the client.

🟢 Recognizing the cause is essential for appropriate fetal monitoring.

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Answer 4

Correct Answers:

Provide humidified oxygen.

Rationale :

☑️ Humidified oxygen helps moisten airway secretions, making them thinner and easier to expectorate or suction.

☑️ Chest physiotherapy is useful but not always suitable immediately prior to suctioning in postoperative tracheostomy clients.

☑️ Prelubricating suction catheters with saline is not recommended due to risk of contamination.

☑️ Hyperventilating with 100% oxygen is used before suctioning but does not thin secretions.

☑️ Moistening secretions promotes airway clearance and patient comfort.

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Answer 5

Correct Answers:

Right lower

Rationale :

✍️ Leopold maneuvers help identify fetal position by palpating fetal parts.

✍️ A round, firm, movable part in the fundus is the fetal head, and a long, smooth surface on the right side indicates the fetal back.

✍️ The fetal heart tones are best heard over the fetal back, so the nurse should auscultate the right lower quadrant.

✍️ Correct location ensures accurate fetal heart rate assessment.

✍️ Misplacement can lead to incorrect interpretations.

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Answer 6

Correct Answers:

Frank breech

Rationale :

🟢 Fetal heart tones located above the umbilicus at midline typically indicate a breech presentation.

🟢 In a Frank breech, the fetus’s buttocks present downward, with legs extended upward.

🟢 A cephalic presentation would place fetal heart tones lower in the abdomen.

🟢 A transverse lie would cause heart tones to be lateral, not midline.

🟢 Correct identification of position guides labor and delivery management.

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Answer 7

Correct Answers:

Slightly above the umbilicus

Rationale :

🟢 At 22 weeks of gestation, the fundal height is expected to be slightly above the umbilicus.

🟢 Fundal height measurement helps estimate fetal growth and gestational age.

🟢 Measuring 3 cm above or below the umbilicus is more typical for later or earlier gestation weeks.

🟢 Accurate palpation helps monitor healthy pregnancy progress.

🟢 Recognizing normal landmarks ensures proper assessment.

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Answer 8

Correct Answers:

A client who is at 28 weeks of gestation and reports painless vaginal bleeding

Rationale :

🟢 Painless vaginal bleeding at 28 weeks can indicate placenta previa, a potentially serious condition requiring immediate assessment.

🟢 Missed periods with spotting may be early pregnancy signs, less urgent.

🟢 Cough and fever at 38 weeks are important but usually less urgent than bleeding in pregnancy.

🟢 Nausea and vomiting at 14 weeks are common and rarely emergencies.

🟢 Prioritizing care based on potential life-threatening risks is critical.

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Answer 9

Correct Answers:

Headache for 30 min

Rationale :

✒️ A persistent headache in a client receiving magnesium sulfate for pre-eclampsia could signal worsening hypertension or impending eclampsia.

✒️ Respirations of 16/min and urinary output of 40 mL in 2 hr are within acceptable ranges but require monitoring.

✒️ Fetal heart rate of 158/min is slightly elevated but may not be an emergency.

✒️ Headache needs immediate reporting to prevent complications.

✒️ Early detection of warning signs improves maternal and fetal outcomes.

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Answer 10

Correct Answers:

"A provider can help you with that after a physical examination."

Rationale :

✍️ The nurse’s response should be professional, nonjudgmental, and supportive.

✍️ Advising to see a healthcare provider after assessment ensures the client receives personalized, safe contraceptive advice.

✍️ Asking about sexual activity directly or making assumptions is inappropriate and may discourage openness.

✍️ Suggesting a method based only on age without assessment can lead to misinformation.

✍️ Respecting confidentiality and encouraging provider consultation is best practice.

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QLexNursing

1 :
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

2 :
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

3 :
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

4 :
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

5 :
A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

6 :
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following
positions?

7 :
A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

8 :
A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

9 :
A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider?

10 :
A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

QLexNursing

1 : A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

2 : A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

3 : A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

4 : A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

5 : A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

6 : A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the followingpositions?

7 : A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

8 : A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

9 : A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider?

10 : A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

1 :
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

2 :
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

3 :
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

4 :
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

5 :
A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

6 :
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following
positions?

7 :
A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

8 :
A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

9 :
A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider?

10 :
A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?