The nurse is caring for a client on the postpartum unit who had a vaginal delivery with epidural anesthesia 2 hours ago. 1. The client presses the call light and tells the nurse she needs to use the bathroom 2. The nurse arrives in the client's room 5 minutes later 3.

The client is getting out of bed alone What is the best response by the nurse?

Suggest catheterizing her this time to prevent the possibility of fainting

Ask the client to lie back down and get her a bedpan

Assist the client to the bathroom

Have the client sit dangling her legs over the side of the bed for 5 minutes

Answer and Explanation

The Correct Answer is C

A. Catheterization may not be necessary at this time and can be uncomfortable for the client.

B. Using a bedpan may not be the most comfortable option for the client, who likely wants to ambulate.
C. Assisting the client to the bathroom is the best response to ensure her safety and prevent falls.

D. Dangling the legs over the side of the bed is not necessary in this situation and may not address the client's need to use the bathroom.

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

Explanation

A. Cervical dilation of 5 cm typically indicates the active phase rather than the latent phase of the first stage of labor.

B. Cervical effacement of 50% is consistent with the latent phase, where cervical effacement is a prominent feature.
C. Contractions lasting about 30 to 45 seconds are characteristic of the latent phase.

D. Moderate contraction intensity is more typical of the active phase of the first stage of labor.

E. Contractions occurring every 5 to 10 minutes are consistent with the latent phase, where contractions are typically less frequent than in the active phase.

A. A previous low transverse uterine incision B. Placenta previa C. A previous classical uterine incision D. Prolapsed umbilical cord E. Breast cancer

Correct Answer is ["B"]

Explanation

A. A previous low transverse uterine incision is a factor that may allow for a trial of labor after cesarean (TOLAC) or a vaginal birth after cesarean (VBAC), rather than an automatic cesarean section.
B. Placenta previa, where the placenta partially or completely covers the cervix, often requires a cesarean section to avoid complications such as bleeding during labor.

C. A previous classical uterine incision, especially if it extends into the upper part of the uterus, is a contraindication for a trial of labor or vaginal birth, usually requiring a repeat cesarean
section.

D. Prolapsed umbilical cord, where the cord precedes the presenting part, can lead to cord compression during contractions, necessitating a prompt cesarean section.
E. Breast cancer is not a direct indication for a cesarean section; it does not impact the mode of delivery in the absence of other obstetric indications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a pregnant client into the labor and delivery unit. Which findings indicate the client is in the latent phase of the first stage of labor? Select all that apply.

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

Explanation

The nurse has received shift report for five clients admitted in labor. Which clients will the nurse anticipate delivering by a cesarean section? Select all that apply.

Correct Answer is ["B"]

Explanation

The nurse assesses a laboring client's cervix and states it is 6 cm dilated and 70% effaced. The client asks what it means to be effaced. Which descriptions will the nurse include when responding to the client? Select all that apply.

The nurse assesses a laboring client's cervix and states it is 6 cm dilated and 70% effaced. The client asks what it means to be effaced. Which descriptions will the nurse include when responding to the client? Select all that apply.

The nurse is assessing the fetal monitoring tracing below. Which type of fetal heart rate variability is pictured here in the top tracing?

The nurse is admitting a client in the first stage of labor with active genital herpes. Which type of birth will the nurse anticipate for this client?

The nurse is completing a fundal assessment for her postpartum clients today. What will the nurse determine when assessing the fundus?