A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

Decrease the rate of IV fluids.

Perform fetal scalp stimulation.

Administer oxygen via a face mask.

Elevate the client's head.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.

Choice B rationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.

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Correct Answer is A

Explanation

Nägele’s Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman’s last menstrual period (LMP).

So, if the last menstrual cycle started on June 21, here’s how you calculate:

Subtract 3 months from June 21, which gives you March 21.
Add 7 days to March 21, which gives you March 28.
Add 1 year to the current year.

So, the estimated date of delivery in the next year would beMarch 28.

A. The client urinates 30 mL/hr. B. The client does not feel the urge to urinate. C. The uterine fundus is 2 cm above the umbilicus. D. The bladder is distended upon palpation.

Correct Answer is A

Explanation

Choice A rationale:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.

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A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is calculating the estimated date of birth using Nägele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated date of delivery in the next year?

Correct Answer is A

Explanation

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

Correct Answer is A

Explanation

A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?.

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A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

A nurse is caring for a client who is in labor and experiences abruptio placenta. Which of the following findings should the nurse expect?

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