A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

Frank breech

Cephalic

Posterior

Transverse

Answer and Explanation

The Correct Answer is A

A. Frank breech position

A. In a frank breech presentation, the baby's buttocks are the presenting part. When the nurse locates fetal heart tones above the client's umbilicus at midline during active labor, it is indicative of a breech presentation, and the frank breech position is one possibility.

B. In a cephalic presentation, which is the most common and ideal position for childbirth, the fetal head is the presenting part, and the fetal heart tones would typically be heard below the umbilicus.

C. In a posterior position, the back of the baby's head is against the mother's spine. Fetal heart tones in this position would be typically heard below the umbilicus.

D. In a transverse lie, the baby is positioned horizontally across the uterus. Fetal heart tones may be heard laterally in this position, not necessarily above the umbilicus at midline.

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Correct Answer is A

Explanation

The correct answer is A. Cervical dilation.

A. Cervical dilation is a definitive sign of labor.

Cervical dilation is the opening of the cervix, and it is a key indicator of the active phase of labor. Measurement of cervical dilation is an essential component of assessing the progress of labor.

B. Brownish vaginal discharge may indicate various things, including the presence of old blood or mucus. While it could be a sign of impending labor, it is not a definitive confirmation of active labor.

C. Amniotic fluid in the vaginal vault could suggest rupture of membranes, but it alone does not confirm the active phase of labor.

D. Pain above the umbilicus is not a specific or conclusive sign of labor. Labor pain typically originates in the lower abdomen and pelvis.

A. Increase the oxytocin infusion to 13 mu/min B. Place client in a side-lying position C. initiate bolus of primary IV fluids D. Apply oxygen at 10 L/min via venturi mask E. Perform sterile vaginal examination (SVE) F. Assign a bishop score

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Increase the oxytocin infusion to 13 mu/min:

Anticipated: This action is anticipated. The nurse may consider adjusting the oxytocin infusion rate based on the progress of labor and the response to the current infusion rate.

Place client in a side-lying position:

Anticipated: Placing the client in a side-lying position is an anticipated action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.

Initiate bolus of primary IV fluids:

Anticipated: Initiating a bolus of primary IV fluids is an anticipated action. Adequate hydration is important during labor, and a bolus may be initiated if there are signs of dehydration or as part of the overall management plan.

Apply oxygen at 10 L/min via a venturi mask:

Anticipated: Applying oxygen at 10 L/min via a venturi mask is an anticipated action. Oxygen may be administered to the mother to improve oxygenation and, consequently, fetal oxygenation.

Perform sterile vaginal examination (SVE):

Nonessential: Based on the information provided, there is no indication for a sterile vaginal examination at this time. The cervical assessment was performed earlier at 0600, and frequent unnecessary SVEs can increase the risk of infection.

Assign a Bishop score:

Nonessential: Assigning a Bishop score is not essential at this point. The client's cervical status was assessed earlier at 0600, and the current focus is on monitoring the progress of labor with oxytocin.

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A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

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Naxlex Comprehensive Predictor Exams

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

Correct Answer is A

Explanation

A nurse is caring for a client who is 42 weeks of gestation Nurses Notes Exhibits Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

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