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 A rationale

While shallow and irregular respirations can be a sign of respiratory distress in newborns, it is not the most indicative symptom. Newborns naturally have irregular breathing patterns, which can include periods of rapid breathing followed by periods of no breathing for up to 10 seconds.

Choice B rationale

A respiratory rate of 50 breaths per minute is within the normal range for a newborn. Newborns typically breathe at a rate of 40 to 60 breaths per minute.

Choice C rationale

Flaring of the nares, or nostrils, is a common sign of respiratory distress in newborns. It indicates that the baby is working hard to breathe.

Choice D rationale

Abdominal breathing with synchronous chest movement is normal in newborns. It is not a sign of respiratory distress.

A. Heat loss. B. Hypoglycemia. C. Fluid balance. D. Bleeding tendencies.

Correct Answer is A

Explanation

Choice A rationale

Heat loss is a significant concern for newborns immediately after birth. Newborns have a large surface area relative to their body weight, which makes them more susceptible to heat loss.

Maintaining a warm environment is crucial to prevent hypothermia, which can lead to complications such as hypoglycemia and respiratory distress.

Choice B rationale

While hypoglycemia is a concern in newborns, especially those born to mothers with diabetes, it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

Choice C rationale

Fluid balance is important in newborns, but it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

Choice D rationale

While newborns do have immature clotting mechanisms, making them more prone to bleeding tendencies, this is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

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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

During a newborn assessment, which symptom, if present, would indicate respiratory distress?

Correct Answer is C

Explanation

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.What priority issue should the nurse address to ensure the newborn’s survival?

Correct Answer is A

Explanation

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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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?