Practice Question
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.
Answer Choices:
Correct Answer:
Cervical dilation
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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This question is from ☑️ W8NR327 EXAM 2 which contains 52 questions.
More Questions from This Exam
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 Choices:
A. Fatigue
B. Constipation
C. Urinary retention
D. Lightening
A nurse is educating a new graduate nurse about forceps-assisted deliveries. What statement by the new graduate indicates a need for further education?
Answer Choices:
A. "Bruising on the newborn's face is likely after forceps delivery."
B. "An episiotomy is often performed when forceps are used for delivery."
C. "A suction cup will be applied to the newborn's head during delivery."
D. "Forceps should only be used if the cervix is fully dilated."
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?
Answer Choices:
A. The fetus is facing the client's back
B. The fetus has descended into the pelvis
C. The fetus is in a vertex position
D. The fetus is in a breech position
The nurse is working in an obstetric clinic. Which client is at greatest risk for preterm labor?
Answer Choices:
A. A client who conceived while taking oral contraception.
B. A client diagnosed with depression who is 23 weeks pregnant.
C. A client who is 34 weeks pregnant with twins.
D. A client who delivered their last baby at 41 weeks.
The nurse is caring for a laboring client. What should the nurse include in the documentation of this fetal monitoring?
Answer Choices:
A. Marked variability
B. Fetal tachycardia
C. Variable decelerations
D. Accelerations present
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Maternal-Child
- Answer Choices: 6