The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

Review the fetal heart rate pattern

Check the pH of the vaginal fluid

Determine cervical dilation.

Palpate the client's bladder

Answer and Explanation

The Correct Answer is D

A. Review the fetal heart rate pattern: Checking the fetal heart rate (FHR) pattern is crucial during labor to ensure the baby is tolerating labor well and there are no signs of fetal distress. However, when the client expresses a need to use the bathroom, this may not be the immediate action required.

B. Check the pH of the vaginal fluid: Checking the pH of the vaginal fluid is not typically an initial action when a laboring client expresses a need to go to the bathroom. Monitoring the pH may be relevant for various reasons, but it's not a primary consideration in this context.

C. Determine cervical dilation: The initial examination revealed the cervix was 3 cm dilated. While reassessing the cervical dilation could provide information about the progress of labor, it may not be the most immediate action needed when the client wants to use the bathroom.

D. Palpate the client's bladder: This is the most relevant action when a laboring client expresses a desire to go to the bathroom. Palpating the bladder can help determine if it's full, which is important because a full bladder might impede labor progress or cause discomfort during contractions.

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Correct Answer is D

Explanation

A. Chromosomal abnormalities:

While an ultrasound can sometimes identify structural abnormalities, it's not the primary tool for detecting chromosomal abnormalities. Genetic testing or procedures like amniocentesis are more specific for this purpose.

B. Sex and size of the infant:

An ultrasound is indeed used to determine the sex of the baby and assess its size and growth.

C. Lecithin-sphingomyelin ratio:

The lecithin-sphingomyelin ratio is typically assessed in tests related to fetal lung maturity, which is not the primary purpose of a routine ultrasound.

D. Fetal growth and gestational age:

This is one of the primary purposes of a routine ultrasound during pregnancy. It helps evaluate the baby's growth and ensures it aligns with the expected gestational age.

A. Obtain blood and urine for prenatal screens B. Explain common complications of pregnancy C. Obtain baseline blood pressure and weight D. Schedule prenatal visits to occur monthly

Correct Answer is A

Explanation

A. Obtain blood and urine for prenatal screens.
This choice is important because it allows the nurse to assess the client's overall health, screen for infections, and identify any potential risks or complications that may impact the pregnancy.

B. Explain common complications of pregnancy.
While educating the client about common complications is valuable, it may not address the immediate need to screen for specific infections or assess the client's current health status. This information can be covered during prenatal education sessions.

C. Obtain baseline blood pressure and weight.
This is a routine part of prenatal care and is important for monitoring the client's health throughout pregnancy. However, if the client has a history of syphilis, obtaining specific prenatal screens (including for syphilis) would be a more targeted and immediate action.

D. Schedule prenatal visits to occur monthly.
Scheduling regular prenatal visits is essential for monitoring the progression of the pregnancy. However, addressing the specific health concerns and obtaining necessary screens take precedence during the initial visit, especially considering the client's history of syphilis.

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The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

Correct Answer is D

Explanation

The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

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