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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Measure vital signs.

Obtain human chorionic gonadotropin levels.

Collect urine sample for urinalysis.

Recommend bed rest.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.

Choice B rationale

Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.

Choice C rationale

Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.

Choice D rationale

Recommending bed rest is not the most appropriate action based on the given symptoms.

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Correct Answer is D

Explanation

Choice A rationale

While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.

Choice B rationale

Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.

Choice C rationale

Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.

Choice D rationale

Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.

A. Estimated amount of fluid. B. Any odor noted when membranes ruptured. C. Time the membranes ruptured. D. Color and consistency of fluid.

Correct Answer is C

Explanation

Choice A rationale

While the estimated amount of fluid can provide some information about the volume of amniotic fluid lost, it is not the most critical piece of information. The amount of fluid can vary and does not necessarily indicate the progression of labor.

Choice B rationale

Any odor noted when the membranes ruptured can be a sign of infection. However, this is not the most crucial information to obtain immediately as it does not directly impact the management of labor.

Choice C rationale

The time the membranes ruptured is the most important information to obtain. This is because the risk of infection increases the longer the time between membrane rupture and delivery.

Knowing the time of rupture helps guide decisions about inducing labor and administering antibiotics to prevent infection.

Choice D rationale

The color and consistency of the fluid can provide information about the presence of meconium or blood, which could indicate fetal distress or placental problems. However, this is not the most critical information to obtain immediately.

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

Correct Answer is D

Explanation

A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?

Correct Answer is C

Explanation

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?