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 C

Explanation

Choice A rationale:

This is incorrect. Intercourse is unlikely to cause rupture of membranes.

Choice B rationale:

This is also incorrect. Intercourse is not likely to result in premature labor.

Choice C rationale:

This is correct. It is generally safe to have intercourse during an uneventful pregnancy.

Choice D rationale:

This is also correct. There are other ways to satisfy sexual needs if intercourse is not possible or desired.

A. "Unfortunately, I'm going to have to stay quite still in bed while it is in place.”. B. "You'll be inserting a special electrode into my baby's scalp.”. C. "This type of monitoring is the most accurate method for our baby.”. D. "This type of monitoring can only be used after my membranes rupture.”.

Correct Answer is A

Explanation

Choice A rationale:

This statement is incorrect. While continuous internal electronic fetal monitoring does limit mobility, it doesn’t require the woman to stay completely still.

Choice B rationale:

This is correct. An electrode may be inserted into the baby’s scalp to monitor heart rate.

Choice C rationale:

This is also correct. Internal monitoring provides the most accurate and continuous data about the baby’s heart rate.

Choice D rationale:

This is correct. The membranes must rupture before the electrode can be inserted.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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:.

Correct Answer is C

Explanation

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?.

Correct Answer is A

Explanation

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?.

A nurse is providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment findings? Select all that apply.

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?.

Your patient is receiving Heparin via a continuous IV infusion at a rate of 1600 units per hour. The bag is labeled N/S 500 mLs and contains Heparin 40,000 units. What rate should the IV pump be set at to deliver this ordered amount of Heparin? mLs/hr.

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as

Which action is a priority when caring for a woman during the fourth stage of labor?.

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?.