Answer Key
Question 1 See full question
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up
... [Show More] this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?
You Selected:
• Latent phase
Correct response:
• Latent phase
Explanation:
The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase.
Remediation:
Question 2 See full question
Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?
You Selected:
• An increase in fetal heart rate variability
Correct response:
• An increased sense of rectal pressure
Explanation:
An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's
behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur.
Remediation:
Question 3 See full question
A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the health care surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make health care decisions for the fetus, who's responsible for making them?
You Selected:
• The client's partner
Correct response:
• The client's partner
Explanation:
Remediation:
Question 4 See full question
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time?
You Selected:
• lying in the left lateral recumbent position
Correct response:
• walking around in the hallway
Explanation:
Most authorities suggest that a woman in an early stage of labor should be allowed to walk if she wishes as long as no complications are present. Birthing centers and single- room maternity units allow women considerable latitude without much supervision at this stage of labor. Gravity and walking can assist the process of labor in some clients. If the client becomes tired, she can rest in bed in the left lateral recumbent position or sit in a comfortable chair. Resting in the left lateral recumbent position improves circulation to the fetus.
Remediation:
Question 5 See full question
While a 31-year-old multigravida at 39 weeks’ gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client’s cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first?
You Selected:
• Auscultate the client's blood pressure.
Correct response:
• Note the color, amount, and odor of the amniotic fluid.
Explanation:
The nurse’s first action when membranes rupture spontaneously is to check the odor, consistency, and volume of the amniotic fluid. Because the fetal head is engaged and at 0 station, there is little likelihood of cord prolapse. However, when the fetal head is not engaged, checking for cord prolapse would be the priority when the membranes rupture spontaneously.
After rupture of the membranes, vaginal examinations should be kept to a minimum to decrease the chance of infection.
Although auscultating the client’s blood pressure is important, it is not the priority following spontaneous rupture of membranes.
Birth is not imminent if the client is 5 cm dilated. However, multigravid clients may progress quickly in labor, especially after rupture of the membranes.
Remediation:
Question 6 See full question
A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include:
You Selected:
• perform sterile vaginal examination, increase IV fluids, and apply oxygen.
Correct response:
• reposition the client, apply oxygen, and increase IV fluids.
Explanation:
Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, oxygen, and IV fluids.
A sterile vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not indicate an imminent birth.
... [Show Less]