The nurse is assessing a client who has been admitted in active labor.
The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom.
What should be the nurse’s first course of action?

Review the pattern of the fetal heart rate.

Check the client’s bladder.

Determine the dilation of the cervix.

Test the pH of the vaginal fluid.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: Reviewing the pattern of the fetal heart rate is important but not the immediate first step when a client in active labor needs to use the restroom. The nurse should first assess the progress of labor.

Choice B rationale: Checking the client's bladder is necessary, especially if the bladder is full, as it can affect labor progress. However, the priority is to assess the cervix first to ensure the client is not in an advanced stage of labor before addressing bladder concerns.

Choice C rationale: Determining the dilation of the cervix is crucial. The need to use the restroom may indicate increased pressure from the presenting part of the fetus, suggesting rapid labor progression. This assessment will help determine if it is safe for the client to ambulate to the restroom or if other immediate actions are needed.

Choice D rationale: Testing the pH of the vaginal fluid can be part of assessing for the presence of amniotic fluid, but it is not the first step when a client in active labor expresses the need to use the restroom. Cervical assessment takes priority in this situation.

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Correct Answer is A

Explanation

Choice A rationale

Iron-deficiency anemia is a common nutritional issue among pregnant teenagers. During pregnancy, the body needs more iron to support the growth and development of the fetus. Teenagers, who are still growing themselves, may already have lower iron stores. Therefore, it is crucial to include information about the importance of iron and how to get enough from the diet in a nutrition education program for pregnant teenagers.

Choice B rationale

While gestational diabetes is a concern during pregnancy, it is not the most crucial topic for a nutrition education program specifically for pregnant teenagers. Gestational diabetes is a condition that can develop during pregnancy in women who don’t already have diabetes. It’s not as common in teenagers as it is in older women.

Choice C rationale

High cholesterol is generally not a primary concern during pregnancy. In fact, it’s normal for cholesterol levels to rise during pregnancy. However, long-term high cholesterol can increase the risk of heart disease.

Choice D rationale

Excessive weight gain can be a concern during pregnancy, but it is not the most crucial topic for a nutrition education program for pregnant teenagers. It’s normal and healthy to gain weight during pregnancy, but the amount should be carefully monitored. Excessive weight gain can lead to complications such as gestational diabetes or high blood pressure.

A. Counsel her to increase her caloric intake. B. Advise the client to breastfeed more frequently. C. Inform her that a decreased need for insulin occurs while breastfeeding. D. Schedule an appointment for the client with the diabetic nurse educator.

Correct Answer is C

Explanation

Choice A rationale

While increasing caloric intake can be beneficial for breastfeeding mothers, it does not directly address the client’s concern about decreased insulin needs.

Choice B rationale

Advising the client to breastfeed more frequently does not directly address the client’s concern about decreased insulin needs.

Choice C rationale

Breastfeeding can lead to a decreased need for insulin in some individuals. This is because lactation requires energy, and this energy demand can affect the mother’s insulin requirements.

Choice D rationale

While scheduling an appointment with the diabetic nurse educator can be helpful, it is not the immediate response to the client’s concern about decreased insulin needs.

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The nurse is assessing a client who has been admitted in active labor. The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom. What should be the nurse’s first course of action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the most crucial topic for the nurse to include in a nutrition education program for pregnant teenagers?

Correct Answer is A

Explanation

A new mother, who is breastfeeding her 4-week-old infant and has type I diabetes, reports that her insulin needs have decreased since the birth of her child.What action should the nurse take?

Correct Answer is C

Explanation

The nurse is about to administer phytonadione to a newborn.Which statement by the parents shows they understand why this medication is being given?

A client informs the nurse that she believes she is pregnant. Which sign or symptom is the best indicator that the client is pregnant?

A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.What should the nurse do next?

A client at 35 weeks gestation complains of pain whenever the baby moves.The nurse notes the client’s temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation.What condition do these findings suggest?

The healthcare provider prescribes magnesium sulfate 4 grams intravenously (IV) to be infused over 20 minutes for a client with preeclampsia. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse program the infusion pump?

A 25-year-old client experienced a severe postpartum hemorrhage following the vaginal birth of twins and is now transferred to the postpartum unit.What complication should the nurse prioritize during the client’s assessment?

A client with gestational diabetes is scheduled for an amniocentesis due to the fetus weighing an estimated 8 pounds (3629 grams) at 36-weeks gestation.What information is being sought through this amniocentesis?

The nurse is assessing a client who has been admitted in active labor.
The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom.
What should be the nurse’s first course of action?