A nurse is caring for a client at term in labor. The client states, “I can’t do this anymore.”. She reports rectal pressure and increasing nausea. SVE (sterile vaginal exam) performed: 9 cm, 100% effaced, +1 station.

Encourage the client to continue pushing.

Prepare the client for delivery.

Administer pain relief as prescribed.

Reassure the client and provide emotional support.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Encouraging the client to continue pushing is not appropriate at this stage. The client is 9 cm dilated, which indicates that she is in the transition phase of labor, not yet fully dilated and ready to push. Pushing at this stage could cause cervical swelling and delay progress.
Choice B rationale
Preparing the client for delivery is the most appropriate action. The client is in the transition phase of labor, with 9 cm dilation, 100% effacement, and +1 station. This indicates that delivery is imminent, and the nurse should prepare for the birth process.
Choice C rationale
Administering pain relief as prescribed may be considered, but it is not the priority action at this stage. The client is in the transition phase, and administering pain relief could interfere with the natural progression of labor. Non-pharmacological support may be more appropriate.
Choice D rationale
Reassuring the client and providing emotional support is important, but it is not the primary action at this stage. The nurse should focus on preparing for delivery while also providing support and reassurance.

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Correct Answer is A

Explanation

Choice A rationale
Late decelerations are a sign of uteroplacental insufficiency and fetal hypoxia. They occur after the peak of a contraction and indicate that the fetus is not receiving enough oxygen. This requires immediate intervention to improve fetal oxygenation and prevent fetal distress.
Choice B rationale
Variability in fetal heart rate of 12 bpm is considered moderate variability, which is a reassuring sign of fetal well-being. It indicates that the fetus has a healthy autonomic nervous system and is not in distress.
Choice C rationale
Accelerations in fetal heart rate are also a reassuring sign. They indicate that the fetus is well-oxygenated and responding appropriately to stimuli. No intervention is needed for accelerations.
Choice D rationale
A baseline fetal heart rate of 140 bpm is within the normal range (110-160 bpm) and does not indicate any immediate concern. It is a sign of a healthy, well-oxygenated fetus.

A. Keep four side rails up. B. Insert an indwelling urinary catheter. C. Check the cervix prior to administering medication. D. Monitor the fetal heart rate (FHR) every hour.

Correct Answer is C

Explanation

Choice A rationale
Keeping four side rails up is a safety measure to prevent falls, but it is not specific to the care of a client in active labor. It is a general safety precaution used for clients who are at risk of falling or have impaired mobility.
Choice B rationale
Inserting an indwelling urinary catheter is not a routine action for a client in active labor. Catheterization is typically reserved for specific medical indications, such as urinary retention or the need for accurate urine output measurement in certain high-risk situations.
Choice C rationale
Checking the cervix prior to administering medication is crucial in active labor. This ensures that the medication is appropriate for the stage of labor and helps avoid complications such as administering pain relief too early or too late, which could affect labor progression and fetal well-being.
Choice D rationale
Monitoring the fetal heart rate (FHR) every hour is important, but it may not be frequent enough in active labor. Continuous or more frequent monitoring is often required to promptly detect any signs of fetal distress and take appropriate actions.

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A nurse is caring for a client at term in labor. The client states, “I can’t do this anymore.”. She reports rectal pressure and increasing nausea. SVE (sterile vaginal exam) performed: 9 cm, 100% effaced, +1 station.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When interpreting a fetal monitoring tracing, which of the following findings would require the nurse to intervene?

Correct Answer is A

Explanation

A nurse is creating the plan of care for a client in active labor. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

The nurse observes variable decelerations on the fetal monitor tracing. Which of the following is a correct interpretation of this finding?

A nurse is caring for a client at 38 weeks gestation who arrived to the triage with complaints of decreased fetal movement. The nurse contacts the provider and reports the findings. The nurse anticipates an order for which of the following?

A nurse is preparing to administer Terbutaline 0.25 mg SQ to a client for tachysystole. Available is terbutaline injection 5 mg/mL. How many mL should the nurse administer? (Use a leading zero if it applies. Do not use a trailing zero.)

The nurse is caring for a client. Which of the following findings would the nurse report to the anesthesia provider?

The nursing preceptor asks the nursing student how to determine the intensity of contractions before placing the client on the electronic fetal monitor. What is the best explanation?

A client has received MSAFP test result. The client is requesting additional testing to determine whether the fetus has a chromosomal abnormality. Which of the following antenatal tests would the nurse anticipate the provider will order?

A nurse is caring for a client who is 39 weeks gestation and having contractions. Which of the following should the nurse recognize as a sign of true labor?