A nurse is caring for a client who is in active labor and has just been examined as being at 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

"Assist the client into a more comfortable position."

"Observe the perineum for signs of crowning."

"Have the client pant or blow during the next contractions to help her refrain from pushing."

"Help the client to the bathroom to empty her bladder."

Answer and Explanation

The Correct Answer is B

Choice A: At 7 cm dilation, the client is in active labor, and assisting her into a more comfortable position may not be appropriate at this stage. It is essential to observe for signs of impending birth and assess the progress of labor.

Choice B: Feeling the urge to push may indicate that the baby is descending and the cervix is fully dilated. The nurse should immediately observe the perineum for signs of crowning (when the baby's head starts to appear at the vaginal opening) to prepare for delivery.

Choice C: If the client is feeling the urge to push and the cervix is fully dilated, panting or blowing through contractions will not be effective. It is important to allow the client to follow her body's natural urges to push.

Choice D: While emptying the bladder is generally recommended during labor to provide more room for the baby to descend, the client's current urge to push suggests that the baby is likely in a lower position, and it might not be safe or feasible to move the client to the bathroom.

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Correct Answer is B

Explanation

A. Incorrect. Increasing the rate of infusion of the IV oxytocin would worsen the uterine hyperstimulation and fetal distress that are indicated by the frequent, long, and strong contractions and uniform decelerations.
B. Correct. Discontinuing the infusion of the IV oxytocin would stop the uterine hyperstimulation and allow the fetus to recover from hypoxia.
C. Incorrect. Decreasing the rate of infusion of the maintenance IV solution would not affect the uterine hyperstimulation or fetal distress, as they are caused by the oxytocin, not by the fluid volume.
D. Incorrect. Slowing the client's rate of breathing would not help with the uterine hyperstimulation or fetal distress, as they are not related to maternal hyperventilation or respiratory alkalosis.

A. "The child might develop encephalitis, a complication of rubella." B. "Exposure to rubella will suppress the newborn's immune response." C. "The newborn is at risk for developing a TORCH infection." D. "The newborn might be actively shedding the virus."

Correct Answer is D

Explanation

Choice A: While rubella can lead to complications like encephalitis, this answer does not address the reason for isolation precautions for the newborn.

Choice B: While rubella can suppress the immune response in general, it does not explain the need for isolation of the newborn specifically.

Choice C: TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes) infections are a group of infections that can be transmitted from mother to fetus during pregnancy. While rubella is part of the TORCH infections, this answer does not specifically address the reason for isolation of the newborn after delivery.

Choice D: Rubella, also known as German measles, is a contagious viral infection. Newborns born to mothers with rubella can be at risk because the virus can be transmitted to them during delivery. The newborn might be actively shedding the virus, which is why isolation precautions are necessary to prevent the spread of the infection to other vulnerable newborns or individuals.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?

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?

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an ROA position. Which of the following fetal presentations should the nurse document in the client's medical record?

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone (Cervidil) gel. Which of the following statements should the nurse include in the teaching?

A nurse in a prenatal clinic is caring for a client who states that she might be pregnant because she feels the baby moving. How does the nurse classify this statement by the client?

A nurse is providing dietary education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

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?