A nurse in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

"All you need to do is relax."

"A pelvic exam is required if you want birth control pills."

"What part of the exam makes you most nervous?"

"Don't worry, I will be with you during the exam."

Answer and Explanation

The Correct Answer is C

Choice A: While relaxation can be helpful during a pelvic examination, it is not the most comprehensive response to address the client's concerns.

Choice B: A pelvic examination is not always required for prescribing birth control pills. In many cases, a healthcare provider can prescribe oral contraceptives based on the client's medical history and other factors without a pelvic exam.

Choice C: This response encourages the client to express her specific concerns and fears related to the examination, allowing the nurse to address them directly and provide appropriate support and reassurance.

Choice D: Although offering support during the exam is important, it does not address the client's nervousness and concerns about the examination itself.

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Correct Answer is A

Explanation

A. Fetal position is persistent occiput posterior: The occiput posterior position (the back of

the baby's head facing the mother's back) can lead to a more challenging and prolonged labor with intense back pain.
B. Fetal attitude is in general flexion: Flexion is the normal fetal attitude for birth and does not contribute to a difficult labor with backache.
C. Fetal lie is longitudinal: Longitudinal lie refers to the baby's position along the mother's spine, but it doesn't specify the position of the baby's back, so it is not directly related to backache.
D. Maternal pelvis is gynecoid: Gynecoid pelvis is the most favorable pelvis shape for childbirth, so it is not likely to cause difficult labor with severe backache.

A. Administer a 500 mL bolus of 5% dextrose in water prior to the epidural administration. B. Inform the client that the anesthetic effect will last for approximately 6 hours. C. Obtain a 30 min electronic fetal monitoring (EFM) strip and prepare to give a bolus of Lactated Ringers solution prior to the epidural administration. D. Have the client stand very still at the bedside with her arms at her side.

Correct Answer is C

Explanation

A: Administering a 500 mL bolus of 5% dextrose in water is not necessary before the epidural administration, and it may not be recommended in active labor as it can increase the risk of fluid overload.

B: The duration of the anesthetic effect of the epidural can vary depending on the medication used, and it is not the nurse's priority during the preparation process.

C: Prior to administering epidural analgesia, the nurse should obtain a 30minute electronic fetal monitoring (EFM) strip to assess the fetal heart rate and monitor for any signs of fetal distress during the procedure.

D: Having the client stand very still with her arms at her side is not practical or necessary for epidural administration and could be uncomfortable for the client during labor.

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A nurse in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

Correct Answer is A

Explanation

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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?

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

A nurse in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

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