A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

Observe for the presence of a nuchal cord.

Prepare to administer oxytocin.

Observe for crowning.

Apply fundal pressure.

Answer and Explanation

The Correct Answer is C

A.   Observe for the presence of a nuchal cord: While this is important, it is not specifically related to the finding of the fetal head at a certain station.
B.   Prepare to administer oxytocin: Oxytocin is a hormone used to induce or augment labor, but there is no indication for its use based solely on the fetal head station.
C.   Observe for crowning: The fetal head at 3+ station indicates significant descent, and crowning may occur soon. Crowning is the appearance of the fetal head at the vaginal opening and indicates that delivery is imminent.
D.   Apply fundal pressure: Fundal pressure is not appropriate at this stage of labor and could cause harm.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is: April 11, 2016

Choice A: April 27, 2016

Reason: Using Naegele’s Rule, the estimated date of delivery (EDD) is calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). For an LMP of May 4, 2015:

Add one year: May 4, 2016
Subtract three months: February 4, 2016
Add seven days: February 11, 2016

April 27, 2016, is incorrect because it does not follow the correct calculation steps.

Choice B: April 11, 2016

Reason: Following Naegele’s Rule:

Add one year: May 4, 2016
Subtract three months: February 4, 2016
Add seven days: February 11, 2016

April 11, 2016, is the correct EDD as it accurately follows the calculation steps.

Choice C: February 27, 2016

Reason: This date is incorrect because it does not follow the correct calculation steps of Naegele’s Rule. The correct EDD should be in April, not February.

Choice D: February 11, 2016

Reason: This date is also incorrect. While it follows the initial steps of Naegele’s Rule, it does not account for the full calculation, which should result in an April date, not February.

A. "You will first feel your baby move in week 24 of pregnancy." B. "The sex of the baby is determined by week 8 of pregnancy." C. "The baby's heartbeat can be seen on ultrasound by about 6 weeks and is audible by a Doppler stethoscope as early as 8 or 9 weeks of pregnancy." D. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of pregnancy."

Correct Answer is C

Explanation

Choice A: Fetal movements, also known as quickening, are usually felt by the mother between weeks 18 and 25 of pregnancy, not specifically at week 24.
Choice B: While the sex of the baby is determined at conception, it is not visually identifiable on ultrasound until around week 16 to 20, depending on the fetus's position and the quality of the ultrasound images.
Choice C: The baby's heartbeat can be visualized on ultrasound as early as 6 weeks of pregnancy. It becomes audible using a Doppler stethoscope around 8 to 9 weeks of pregnancy.
Choice D: Lanugo, the fine hair covering the baby's body, usually appears around weeks 20 to 24 of pregnancy and begins to diminish later in pregnancy, not specifically at week 36.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. The nurse uses Naegele's Rule to calculate the correct EDD:

Correct Answer is D

Explanation

A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when he observes which of the following patterns?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

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 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?

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?