A nurse is assessing a client who is in labor and notes that the fetal head is visible at the vaginal opening but does not advance with pushing.

The nurse should identify this finding as which of the following?

Crowning

Molding

Caput succedaneum

Shoulder dystocia.

Answer and Explanation

The Correct Answer is A

Crowning is when the fetal head is visible at the vaginal opening and does not slip back in with each contraction. This indicates that the baby is ready to be born and the mother should stop pushing to avoid tearing or the need for an episiotomy.

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Correct Answer is ["A","C"]

Explanation

Applying suprapubic pressure and assisting the provider with McRoberts maneuver are two nursing interventions that can help dislodge the impacted shoulder and facilitate the delivery of the baby.

Normal ranges for fetal heart rate are 110 to 160 beats per minute, and for maternal blood pressure are 110/70 to 140/90 mm Hg.

A. A boggy uterus B. A firm fundus at the umbilicus C. Excessive lochia rubra D. Clots larger than a quarter E. A pulse rate of 110/min

Correct Answer is ["A"]

Explanation

A boggy uterus is a sign of uterine atony, which is the failure of the uterus to contract sufficiently after childbirth.

This can lead to excessive bleeding and postpartum hemorrhage.

A firm fundus at the umbilicus is a normal finding after delivery and indicates that the uterus is contracting well.

Excessive lochia rubra is also a sign of uterine atony and postpartum hemorrhage.Lochia rubra is the vaginal discharge composed of blood, mucus, and tissue from the placenta and the uterus lining that occurs after childbirth.

It is normal for the first 3 to 4 days, but it should gradually decrease in amount and change in color.

Clots larger than a quarter are abnormal and indicate excessive bleeding.

A pulse rate of 110/min is a sign of tachycardia, which can be caused by blood loss, infection, or pain.

A normal pulse rate for an adult is between 60 and 100 beats per minute.

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A nurse is assessing a client who is in labor and notes that the fetal head is visible at the vaginal opening but does not advance with pushing. The nurse should identify this finding as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor and experiencing shoulder dystocia. Which of the following actions should the nurse take? (Select all that apply.).

Correct Answer is ["A","C"]

Explanation

A nurse is assessing a client who had a prolonged labor and is at risk for uterine atony. Which of the following findings should indicate to the nurse that the client has this condition? Select all that apply.

Correct Answer is ["A"]

Explanation

A nurse is evaluating a client who has prolonged labor and suspects uterine rupture. Which of the following findings should alert the nurse to this complication?

A nurse is assessing a client who is in labor and has been pushing for 3 hours with no progress. The nurse should identify that this client is at risk for which of the following complications? (Select all that apply.).

A nurse is caring for a client who has prolonged labor and is at risk for infection. Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

A nurse is caring for a client who had a vacuum-assisted delivery due to prolonged labor and is at risk for developing a hematoma in the perineal area. Which of the following manifestations should alert the nurse to this complication?

A nurse is assessing a client who is in labor and notes that the fetal head is visible at the vaginal opening but does not advance with pushing. The nurse should identify this finding as which of the following?

A gush of blood is noted with the rupture of membranes. On palpation, the uterus is soft (i.e., relaxed) and the patient is not reporting any pain. An FHR deceleration down to 90 bpm is noted. What does the nurse suspect has happened?

A nurse is preparing to assist with an emergency cesarean delivery for a client who has a ruptured uterus. Which of the following equipment should the nurse have readily available? (Select all that apply.)

A nurse is reviewing the partograph of a client in labor. The nurse notes that the cervical dilation curve is above the alert line and below the action line. What does this indicate?

A nurse is assessing a client who is in labor and notes that the fetal head is visible at the vaginal opening but does not advance with pushing.

The nurse should identify this finding as which of the following?