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A woman who is gravida 3 para 2 enters the intrapartum unit. The most important initial nursing assessments are:

If she has had prenatal care.

Membrane status and her EDD/EDC.

Time of last food intake and fasting blood sugar.

Pain level and birth plan.

Answer and Explanation

The Correct Answer is B

A. Prenatal care history is important but not as urgent as membrane status and estimated delivery date.

B. Membrane status and estimated delivery date are critical for assessing the stage of labor and planning care.

C. Fasting blood sugar is relevant in diabetic patients but not an immediate priority.

D. Pain level and birth plan are important but secondary to assessing labor progress.

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Correct Answer is ["C","E","F"]

Explanation

A. The active stage of labor typically begins when cervical dilation is around 4 cm. LC’s dilation of 6 cm suggests that she is already in the active phase, but this is not confirmed based on this vaginal exam alone.

B. LC is not 80% dilated; the figure 6/80/-1 indicates 6 cm dilation, 80% effaced, and -1 station (fetal head is still above the ischial spines).

C. The fetal station of -1 indicates that the presenting part (head) is 1 cm above the pelvic outlet, which is consistent with this description.

D. The presenting part being 1 cm below the ischial spines would indicate a station of +1, which is not described here.

E. The cervix is 80% effaced, meaning it is more than halfway thinned, which is correct.

F. With a dilation of 6 cm, LC is in the active phase of labor, not the latent phase, but the question refers to the latent phase for comparison.

A. 3 lbs per week for each week of pregnancy B. 35-40 lbs throughout the entire pregnancy C. 15-20 lbs throughout the entire pregnancy D. Less than a 1lb per week for each week of pregnancy.

Correct Answer is C

Explanation

A. 3 lbs per week is too high for someone with a BMI of 16 and could lead to excessive weight gain.

B. 35-40 lbs is too broad and may not be suitable for this patient's low BMI, which typically requires a more controlled approach.

C. For a patient with a BMI of 16 (underweight), the recommended weight gain during pregnancy is generally between 28-40 pounds, but given the patient's lower weight, 15-20 lbs is a realistic goal for weight gain, allowing for healthy fetal development.

D. Less than 1lb per week could be too slow, potentially leading to insufficient fetal growth.

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A woman who is gravida 3 para 2 enters the intrapartum unit. The most important initial nursing assessments are:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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