A nurse is providing care to a client in labor.

A pelvic exam reveals a vertex presentation with the presenting part tilted toward the left side of the mother's pelvis and directed toward the anterior portion of the pelvis.

When developing this client's plan of care, which intervention would the nurse include?

Implementing measures for a vaginal birth.

Instituting continuous internal fetal monitoring.

Assisting with artificial rupture of the membranes.

Preparing the client for a cesarean birth.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Implementing measures for a vaginal birth is a reasonable intervention as the baby is in a favorable position for a normal delivery.

Choice B rationale:

Continuous internal fetal monitoring is not necessary unless there are complications or high-risk factors present.

Choice C rationale:

Artificial rupture of the membranes can be done to induce or augment labor, but it’s not necessary in this case.

Choice D rationale:

Preparing for a cesarean birth is not necessary as the baby is in a favorable position for a vaginal birth.

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Correct Answer is B

Explanation

Choice A rationale:

Perinatal transmission is a way HIV can be transmitted, but it’s not the primary means for adolescents.

Choice B rationale:

Sexual intercourse is the primary means by which adolescents are exposed to HIV.

Choice C rationale:

Sharing needles for IV drug use is a risk factor, but not the primary means for adolescents.

Choice D rationale:

Blood transfusion was a common means of transmission in the past, but it’s rare now due to rigorous screening.

A. Cervical dilation (dilatation). B. Fetal movement through the birth canal. C. Placental separation. D. Regular contractions.

Correct Answer is A

Explanation

Choice A rationale:

Cervical dilation is the major change occurring during the first stage of labor. This stage begins with the onset of labor and ends when the cervix is fully dilated.

Choice B rationale:

Fetal movement through the birth canal primarily occurs during the second stage of labor, not the first.

Choice C rationale:

Placental separation occurs during the third stage of labor, after the baby is born.

Choice D rationale:

Regular contractions do occur during the first stage of labor, but they are not the major change. The major change is cervical dilation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After teaching a group of adolescents about HIV, the nurse asks them to identify the primary means by which adolescents are exposed to the virus. The nurse determines that the teaching was successful when the group identifies which means of exposure?.

Correct Answer is B

Explanation

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

Correct Answer is A

Explanation

A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome?.

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station?.

Which measure would the nurse include in the teaching plan for a woman to reduce the risk of osteoporosis after menopause?.

The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. What will the mother likely experience at that time?.

A nurse palpates a woman's fundus to determine contraction intensity. What would be most appropriate for the nurse to use for palpation?.

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect?

The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part?.

A woman in the 34th week of pregnancy says to the nurse, "I still feel like having intercourse with my husband.”. The woman's pregnancy has been uneventful. The nurse responds based on the understanding that:.