Question

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Answer 1

Correct Answers:

Transition

Rationale :

🔶 The transition phase is the final stage of the first stage of labor, occurring when the cervix dilates from 8 to 10 cm.

🔶 This phase is characterized by strong contractions, occurring every 2 to 3 minutes and lasting up to 90 seconds, as described in the scenario.

🔶 The client’s increasing rectal pressure is also a hallmark of this intense stage, signaling imminent complete dilation.

🔶 Nursing support during this phase is crucial, as women may feel overwhelmed due to pain and pressure sensations.

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Answer 2

Correct Answers:

Demonstrate to the client how to perform a newborn bath

Rationale :

🟣 The taking-hold phase begins within a few days postpartum and lasts several days.

🟣 In this stage, the mother becomes more independent and interested in newborn care and learning.

🟣 It is an optimal time for nurses to teach practical skills, such as newborn bathing and feeding.

🟣 The mother’s focus shifts from herself to her baby’s needs during this phase.

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Answer 3

Correct Answers:

Apply internal upward pressure to the presenting part using two gloved fingers.

Rationale :

🔴 A prolapsed cord is an obstetric emergency that can lead to fetal hypoxia due to cord compression.

🔴 The immediate nursing priority is to relieve pressure on the cord by applying upward pressure with sterile-gloved fingers.

🔴 Simultaneously, help should be sought and preparation for an emergency delivery (often cesarean) should begin.

🔴 Additional measures such as positioning and oxygen may follow, but relieving pressure takes precedence.

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Answer 4

Correct Answers:

Monitor the clients blood pressure every minute following the first dose of anesthetic solution.

Rationale :

🟡 Hypotension is a common adverse effect of epidural anesthesia due to sympathetic blockade.

🟡 Frequent blood pressure monitoring, especially every minute after the first dose, helps detect sudden drops in pressure.

🟡 Managing hypotension quickly is essential to maintain adequate placental perfusion.

🟡 Other actions (like IV fluid preload) are supportive but not substitutes for close BP monitoring.

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Answer 5

Correct Answers:

"A blood glucose of 130 to 140 is considered a positive screening result.

Rationale :

🔵 The 1-hour glucose tolerance test (GTT) is a screening tool for gestational diabetes done between 24–28 weeks.

🔵 A glucose level ≥130 to 140 mg/dL is considered abnormal and warrants a 3-hour glucose tolerance test.

🔵 Fasting is not required, and carbohydrate restriction beforehand is unnecessary.

🔵 This test assesses how efficiently the body processes glucose during pregnancy.

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Answer 6

Correct Answers:

Bilirubin 9 mg/dL

Rationale :

⚫ At 4 hours old, a bilirubin level of 9 mg/dL is considered elevated and abnormal.

⚫ Normal bilirubin levels at birth are typically under 6 mg/dL; higher values increase risk for kernicterus.

⚫ Early-onset hyperbilirubinemia requires prompt attention and possible phototherapy.

⚫ The other lab values listed are within normal ranges for newborns.

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Answer 7

Correct Answers:

"You should leave the diaphragm in place tor at least 6 hours after intercourse."

Rationale :

🟤 The diaphragm is a barrier contraceptive method and should be left in place for at least 6 hours after sex to allow spermicide to be effective.

🟤 It should be removed within 24 hours to reduce risk of toxic shock syndrome.

🟤 Oil-based lubricants should be avoided as they can degrade the latex material.

🟤 The bladder should be emptied before insertion to reduce risk of injury.

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Answer 8

Correct Answers:

Blood glucose 30 mg/dL

Rationale :

🟢 A blood glucose of 30 mg/dL at 24 hours is critically low; newborns should maintain glucose levels above 45 mg/dL at this age.

🟢 Hypoglycemia in newborns can cause jitteriness, apnea, lethargy, and seizures if untreated.

🟢 Prompt intervention such as feeding or IV glucose may be needed.

🟢 The other values are within acceptable newborn ranges at 24 hours.

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Answer 9

Correct Answers:

"I will continue taking my insulin if I experience nausea and vomiting

Rationale :

🔷 Clients with preexisting diabetes should continue insulin therapy even when ill to prevent hyperglycemia and ketoacidosis.

🔷 Illness often causes increased stress hormones, raising blood glucose levels.

🔷 They should monitor glucose more frequently and maintain hydration.

🔷 Exercise when blood glucose is ≥250 mg/dL is not advised due to risk of ketoacidosis.

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Answer 10

Correct Answers:

Assist the client to empty her bladder.

Rationale :

🟥 A deviated uterus, particularly to the right and above the umbilicus, suggests a distended bladder, which can hinder uterine contraction and lead to postpartum hemorrhage.

🟥 Bladder emptying allows the uterus to contract effectively and descend into the pelvis.

🟥 This is a first-line, non-invasive intervention before more advanced treatments.

🟥 Simethicone and repositioning are not indicated in this context.

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QLexNursing

2 :
A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

3 :
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina.

4 :
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

5 :
A nurse is teaching a client who is at 24 weeks of gestation regarding a I-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

6 :
A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

7 :
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?

8 :
A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

9 :
A nurse is teaching a client who has presentational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

QLexNursing

2 : A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

3 : A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina.

4 : A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

5 : A nurse is teaching a client who is at 24 weeks of gestation regarding a I-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

6 : A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

7 : A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?

8 : A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

9 : A nurse is teaching a client who has presentational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

10 : A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

2 :
A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

3 :
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina.

4 :
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

5 :
A nurse is teaching a client who is at 24 weeks of gestation regarding a I-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

6 :
A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

7 :
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?

8 :
A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

9 :
A nurse is teaching a client who has presentational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?