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 C

Explanation

Choice C rationale

Amenorrhea, or the absence of menstruation, is often the first and most reliable sign of pregnancy. If a woman is in her childbearing years and a week or more has passed without the start of an expected menstrual cycle, she might be pregnant.

Choice A rationale

Hegar’s sign is a physical examination finding that can be indicative of pregnancy. However, it is not typically used as the primary indicator of pregnancy because it requires a pelvic examination and is less reliable than other signs such as amenorrhea.

Choice B rationale

While breast tenderness can be a symptom of early pregnancy, it is not the most reliable indicator. Many other conditions or factors, such as hormonal fluctuations related to the menstrual cycle, can also cause breast tenderness.

Choice D rationale

Morning sickness, characterized by nausea and vomiting, is a common symptom of early pregnancy. However, not all pregnant women experience morning sickness, and it can also be caused by other conditions. Therefore, it is not the most reliable indicator of pregnancy.

A. Conduct a gestational age assessment. B. Weigh and measure the newborn. C. Evaluate the neonatal reflexes’ reactivity. D. Perform a drug screen for cocaine.

Correct Answer is D

Explanation

Choice A rationale

While conducting a gestational age assessment is important, it is not the priority in this situation.

Choice B rationale

Weighing and measuring the newborn are routine procedures, but they are not the priority when the newborn is showing signs of distress.

Choice C rationale

Evaluating the neonatal reflexes’ reactivity is an important part of the newborn assessment, but it is not the priority in this situation.

Choice D rationale

Performing a drug screen for cocaine is the priority in this situation. The symptoms described - shakiness, a fast heart rate, and high blood pressure - can be signs of neonatal abstinence syndrome, which can occur if the mother used certain drugs, such as cocaine, during pregnancy.

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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?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.Which assessment action should the nurse prioritize?

Correct Answer is D

Explanation

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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?