A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

"This always happens by the end of the first trimester of pregnancy."

"This will occur during the last trimester of pregnancy."

"This usually happens between the fourth and fifth months of pregnancy"

"This will happen once the uterus begins to rise out of the pelvis."

Answer and Explanation

The Correct Answer is C

A.   "This always happens by the end of the first trimester of pregnancy.": Quickening typically occurs later in pregnancy, not by the end of the first trimester.
B.   "This will occur during the last trimester of pregnancy.": Quickening occurs much earlier than the last trimester.
C.   "This usually happens between the fourth and fifth months of pregnancy.": Quickening, which is the first perception of fetal movements by the mother, generally occurs between 16 to 20 weeks of gestation.
D.   "This will happen once the uterus begins to rise out of the pelvis.": Quickening does not directly correlate with the rising of the uterus out of the pelvis.

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Correct Answer is D

Explanation

Choice A: It is not accurate to say that a repeat cesarean birth will always be safer. The decision for a repeat cesarean or a trial of labor after cesarean (TOLAC) depends on various factors, including the client's medical history and the type of incision used in the previous cesarean.

Choice B: While there are multiple factors to consider, the nurse can still provide general information about the possibility of attempting a vaginal birth after cesarean (VBAC).

Choice C: While focusing on the health of the newborn is important, the client's question about the possibility of a future VBAC can be addressed without dismissing her concerns.

Choice D: The type of incision used in the previous cesarean birth (such as low transverse incision) is a significant factor in determining the eligibility for a VBAC in subsequent pregnancies. Clients with certain types of incisions may have a higher likelihood of success with a VBAC.

A. Insert an indwelling urinary catheter to maintain an empty blaadder at all times. B. Keep four side rails up while the client is in bed, maintaining strict bedrest. C. Monitor the fetal heart rate (FHR) hourly during active labor. D. Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

Correct Answer is D

Explanation

Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times.

Routinely inserting an indwelling urinary catheter is not necessary for maintaining an empty bladder during labor. While it is important to ensure the client has a voiding schedule, the use of an indwelling catheter should be reserved for specific medical indications, such as when the client is unable to void or has received an epidural. Indwelling catheters can increase the risk of catheter-associated urinary tract infections (CAUTIs) and should be used judiciously.

Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest.

Keeping all four side rails up and maintaining strict bedrest is not appropriate during active labor. This practice can limit the client’s movement, which is essential for comfort and progress during labor. Movement and changing positions can help labor progress and reduce pain. Strict bedrest is generally reserved for specific medical conditions, such as preterm labor or other complications.

Choice C: Monitor the fetal heart rate (FHR) hourly during active labor.

Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus. However, hourly monitoring may not be sufficient. Guidelines recommend more frequent monitoring, typically every 15-30 minutes during the active phase of labor and every 5-15 minutes during the second stage. Continuous electronic fetal monitoring may be used for high-risk pregnancies or if there are signs of fetal distress.

Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

Checking the cervix to determine how close the time of delivery may be prior to analgesic administration is important. This practice helps ensure that analgesics are administered at an appropriate time, avoiding potential complications such as delayed delivery or inadequate pain relief. Cervical checks provide valuable information about the progress of labor and help guide clinical decisions regarding pain management and delivery planning.

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A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?

Correct Answer is D

Explanation

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times.

Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest.

Choice C: Monitor the fetal heart rate (FHR) hourly during active labor.

Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

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